Steps Of Robot-assisted Radical Prostatectomy Research Articles

Robot-assisted radical prostatectomy training: Description of a canine cadaveric model.

Assess the relevance of a canine model in robot-assisted radical prostatectomy (RARP) training. Step-by-step RARP was performed in five dog cadavers using a Da Vinci Si® Surgical Robot (Intuitive Surgical, Inc.). The steps were defined according to the RARP score, a validated training tool describing 17 key steps and four levels of difficulty; each step was scored to reflect the anatomical and technical similarities, realism of dissection, and face validity of the canine model compared to the human procedure. Fourteen steps were performed during each procedure. Face validity was scored as high or very high for five of the nine steps of difficulty levels 1 and 2 as well as five of the eight steps of difficulty levels 3 and 4, especially nerve preservation, vesicourethral anastomosis and lymph node dissection. The cadaveric canine model seems to be a realistic and relevant training model for key steps of RARP.

Factors Affecting Transperitoneal Robot-Assisted Laparoscopic Radical Prostatectomy.

Objectives: To evaluate the impact of body mass index (BMI), preoperative risk classification, previous inguinal herniotomy, and abdominal operations on several steps of robot-assisted radical prostatectomy (RARP) and lymph node (LN) involvement. Methods: A total number of 225 consecutive patients were included in the study who underwent transperitoneal RARP by 1 surgeon. We defined the following parameters as dependent variables: duration of prostatectomy, duration of pelvic lymphadenectomy, incision to suture time, console time, number of dissected LNs and number of positive LNs for metastasis. We assessed the impact of the following covariates using univariate nonparametric and multivariate analysis: BMI, preoperative D'Amico risk classification, history of inguinal herniotomy, and previous abdominal operations. Results: We observed a statistically significant difference among our three BMI groups (<25, ≥25 and <30, and ≥30 kg/m2) regarding pelvic lymphadenectomy and LN metastasis. Moreover, among the three risk groups (low, intermediate, and high) duration of prostatectomy, pelvic lymphadenectomy, and LN metastasis were statistically different. Previous abdominal operations have been also demonstrated to significantly influence the pelvic lymphadenectomy. In addition, our multivariate model proved the impact of our covariates on pelvic lymphadenectomy. Conclusions: Our findings highlight the impact of BMI and preoperative risk on various steps of RARP. We revealed longer duration of pelvic lymphadenectomy and more nodal yield in patients with higher BMI and high-risk disease. Therefore, we suggest that BMI and risk classification according to D'Amico should be taken into account while a RARP is being planned.

PD57-07 AUTOMATED PERFORMANCE METRICS THAT ANTICIPATE EARLY AND LATE URINARY CONTINENCE RECOVERY AFTER ROBOT-ASSISTED RADICAL PROSTATECTOMY

You have accessJournal of UrologyProstate Cancer: Localized: Surgical Therapy IV (PD57)1 Sep 2021PD57-07 AUTOMATED PERFORMANCE METRICS THAT ANTICIPATE EARLY AND LATE URINARY CONTINENCE RECOVERY AFTER ROBOT-ASSISTED RADICAL PROSTATECTOMY Runzhuo Ma, Ryan S. Lee, Sharath S. Reddy, Jessica H. Nguyen, Steven Cen, Katarina Urbanova, Joern H. Witt, Inderbir S. Gill, Christian Wagner, and Andrew J. Hung Runzhuo MaRunzhuo Ma More articles by this author , Ryan S. LeeRyan S. Lee More articles by this author , Sharath S. ReddySharath S. Reddy More articles by this author , Jessica H. NguyenJessica H. Nguyen More articles by this author , Steven CenSteven Cen More articles by this author , Katarina UrbanovaKatarina Urbanova More articles by this author , Joern H. WittJoern H. Witt More articles by this author , Inderbir S. GillInderbir S. Gill More articles by this author , Christian WagnerChristian Wagner More articles by this author , and Andrew J. HungAndrew J. Hung More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002091.07AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Automated performance metrics (APMs), objective metrics derived from kinematic/system events data and captured by a systems data recorder (Intuitive Surgical) during surgery, are a validated surgical assessment tool. We previously showed APMs from certain steps of robot-assisted radical prostatectomy (RARP) to be predictors of early urinary continence recovery. Having expanded our cohort to include two high-volume centers with longer follow-up, we now explore how APMs may be associated with both early and late urinary continence recovery after RARP. METHODS: Non-teaching RARP cases from 2016-2019 from two centers were included in this study. Non-teaching cases were defined as cases in which an expert surgeon (>100 prior robotic surgery cases) performed all seven major steps, including anterior/posterior bladder neck dissection (BND), left/right neurovascular bundle (NVB) preservation, apical dissection, and posterior/anterior vesicourethral anastomosis. The outcome of interest was 6-month (early) and 12-month (late) continence recovery status. Continence was defined as using 0 or 1 safety pad per day. Decision tree (CART©) was used to predict outcomes. APMs from the seven major steps (38 x 7), 9 patient factors, and 5 treatment factors were utilized in the model. Gini impurity was used as splitting criteria and a 10-fold cross-validation was conducted. Out-of-bag Gini impurity index was used for feature ranking. RESULTS: 110 non-teaching RARP cases from 22 expert surgeons were included in this study. At 6 and 12 months, 59.1% (65/110) and 74.5% (82/110) of cases recovered continence, respectively. In the training phase of the model, the 6- and 12-month continence recovery prediction achieved 71.8% and 65.5% accuracy, respectively; in the testing phase, the accuracies slightly decreased to 67.3% and 61.8%. At both time points, the top 10 features came from APMs; none were patient factors. For 6-month continence status prediction, all top 10 features came from anterior BND. For 12-month continence status prediction, 6/10 came from anterior BND, 3/10 came from left NVB, and 1/10 came from posterior BND. CONCLUSIONS: Surgical performance, as measured by APMs, was the strongest predicter of both early and late continence recovery after RARP. Bladder neck dissection was the most important surgical performance step for early continence recovery in this non-teaching case cohort, while late continence recovery was affected by performance in more varied steps. Source of Funding: This study was funded in part by an Intuitive Surgical Clinical Grant; Intuitive Surgical provided the systems data recorder. Research reported in this publication was also supported in part by the National Institute Of Biomedical Imaging And Bioengineering of the National Institutes of Health under Award Number K23EB026493. © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e1012-e1012 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Runzhuo Ma More articles by this author Ryan S. Lee More articles by this author Sharath S. Reddy More articles by this author Jessica H. Nguyen More articles by this author Steven Cen More articles by this author Katarina Urbanova More articles by this author Joern H. Witt More articles by this author Inderbir S. Gill More articles by this author Christian Wagner More articles by this author Andrew J. Hung More articles by this author Expand All Advertisement Loading ...

Using video review to understand the technical variation of robot-assisted radical prostatectomy in a statewide surgical collaborative.

Video assessment is an emerging tool for understanding surgical technique. Patient outcomes after robot-assisted radical prostatectomy (RARP) may be linked to technical aspects of the procedure. In an effort to refine surgical approaches and improve outcomes, we sought to understand technical variation for the key steps of RARP in a surgical collaborative. The Michigan Urological Surgery Improvement Collaborative (MUSIC) is a statewide quality improvement collaborative with the aim of improving prostate cancer care. MUSIC surgeons were invited to submit representative complete videos of nerve-sparing RARP for blinded analysis. We also analyzed peri-operative outcomes from these surgeons in the registry. Surgical video data from 20 unique surgeons identified many variations in technique and time to complete different steps. Common to all surgeons was a transperitoneal approach and a running urethrovesical anastomosis. Prior to anastomosis, 25% surgeons undertook a posterior reconstruction and 30% employed urethral suspension. 65% surgeons approached the seminal vesicle anteriorly. For control of the dorsal vein complex, suture ligation was used in 60%, and vascular stapler was 15%. The majority (80%) of surgeons employed clips for managing pedicles. In examining patient outcomes for surgeons, peri-operative outcomes were not correlated with surgeon's operative time; however, surgeons with an EBL > 400ml had significant difference among the five different techniques employed. Despite the worldwide popularity of RARP, the operation is still far from standardized. Correlating variation in technique with clinical outcomes may help provide objective data to support best practices with the goal to improve patient outcomes.

PD38-11 USING VIDEO ANALYSIS TO UNDERSTAND THE TECHNICAL VARIATION OF ROBOT-ASSISTED RADICAL PROSTATECTOMY (RARP) IN A STATEWIDE SURGICAL COLLABORATIVE

You have accessJournal of UrologyProstate Cancer: Localized: Surgical Therapy V1 Apr 2018PD38-11 USING VIDEO ANALYSIS TO UNDERSTAND THE TECHNICAL VARIATION OF ROBOT-ASSISTED RADICAL PROSTATECTOMY (RARP) IN A STATEWIDE SURGICAL COLLABORATIVE Parin Patel, Tae Kim, Zack Prebay, Jaya Telang, Susan Linsell, Eduardo Kleer, David Miller, James O. Peabody, Khurshid R. Ghani, and William K. Johnston III Parin PatelParin Patel More articles by this author , Tae KimTae Kim More articles by this author , Zack PrebayZack Prebay More articles by this author , Jaya TelangJaya Telang More articles by this author , Susan LinsellSusan Linsell More articles by this author , Eduardo KleerEduardo Kleer More articles by this author , David MillerDavid Miller More articles by this author , James O. PeabodyJames O. Peabody More articles by this author , Khurshid R. GhaniKhurshid R. Ghani More articles by this author , and William K. Johnston IIIWilliam K. Johnston III More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.1758AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Video assessment is an emerging tool for understanding variation in surgical technique. Despite its widespread adoption, patient outcomes for RARP may be linked to technical aspects of the procedure. In an effort to refine surgical approaches and improve outcomes, we sought to understand technical variation for the key steps of RARP in a statewide collaborative. METHODS The Michigan Urological Surgery Improvement Collaborative (MUSIC) is a statewide quality improvement collaborative consisting of 260 urologists from 44 diverse community and academic practices, with the aim of improving prostate cancer care. Representative complete videos of nerve-sparing RARP were voluntarily submitted to the MUSIC coordinating center. The duration and variations in the tasks performed during each part were captured. RESULTS The anterior approach was used by 65% of surgeons (vs posterior) for the seminal vesicle (SV) dissection. Captured video analysis data identified variation in time to complete different steps (Figure 1): bladder takedown (2-24 mins), endopelvic fascia dissection (4-11 mins), dorsal venous complex (DVC) control (2-10 mins), bladder neck dissection (7-30 mins), SV dissection (9-32 mins), nerve-sparing/pedicle control (8-33 mins), apical dissection (4-17 mins), and anastomosis (17-44 mins). Seven different permutations involving suture, staples and electrocautery for dividing/controlling the DVC were used. Management of the pedicle/nerve-sparing was performed using hem-o-lok clips (15), Enseal tissue sealer (4), and titanium clips (1). Prior to anastomosis, only 5/20 undertook a posterior reconstruction. A non-barbed (vs barbed) running suture (12/20) was the predominant anastomosis method and 6/20 placed a urethral suspension stitch. At the end, 50% of surgeons performed a bladder leak test with 11/20 surgeons placing drains regardless of the result. Two surgeons utilized SP tubes for bladder drainage. CONCLUSIONS RARP technique is not uniform. Video analysis identified variation in (1) time to complete each step (2) methods for DVC control, (3) nerve-sparing technique, and (4) performance of the urethrovesical anastomosis. Future efforts linking differences in technique with clinical outcomes can provide objective evidence to support best practices. © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e740-e741 Advertisement Copyright & Permissions© 2018MetricsAuthor Information Parin Patel More articles by this author Tae Kim More articles by this author Zack Prebay More articles by this author Jaya Telang More articles by this author Susan Linsell More articles by this author Eduardo Kleer More articles by this author David Miller More articles by this author James O. Peabody More articles by this author Khurshid R. Ghani More articles by this author William K. Johnston III More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

New steps of robot-assisted radical prostatectomy using the extraperitoneal approach: a propensity-score matched comparison between extraperitoneal and transperitoneal approach in Japanese patients

BackgroundRobot-assisted radical prostatectomy (RARP) is commonly performed using the transperitoneal (TP) approach with six trocars over an 8-cm distance in the steep Trendelenburg position. In this study, we investigated the feasibility and the benefit of using the extraperitoneal (EP) approach with six trocars over a 4-cm distance in a flat or 5° Trendelenburg position. We also introduced four new steps to the surgical procedure and compared the surgical results and complications between the EP and TP approach using propensity score matching.MethodsBetween August 2012 and August 2016, 200 consecutive patients without any physical restrictions underwent RARP with the EP approach in a less than 5° Trendelenburg position, and 428 consecutive patients underwent RARP with the TP approach in a steep Trendelenburg position. Four new steps to RARP using the EP approach were developed: 1) arranging six trocars; 2) creating the EP space using laparoscopic forceps; 3) holding the separated prostate in the EP space outside the robotic view; and 4) preventing a postoperative inguinal hernia. Clinicopathological results and complications were compared between the EP and TP approaches using propensity score matching. Propensity scores were calculated for each patient using multivariate logistic regression based on the preoperative covariates.ResultsAll 200 patients safely underwent RARP using the EP approach. The mean volume of estimated blood loss and duration of indwelling urethral catheter use were significantly lower with the EP approach than the TP approach (139.9 vs 184.9 mL, p = 0.03 and 5.6 vs 7.7 days, p < 0.01, respectively). No significant differences in the positive surgical margin were observed. None of the patients developed an inguinal hernia postoperatively after we introduced this technique.ConclusionsThe EP approach to RARP was safely performed regardless of patient physique or contraindications to a steep Trendelenburg position. Our method, which involved using the EP approach to perform RARP, can decrease the amount of perioperative blood loss, the duration of indwelling urethral catheter use, and the incidence of postoperative inguinal hernia development.

Development and Validation of Objective Performance Metrics for Robot-Assisted Radical Prostatectomy: A Pilot Study.

We explore and validate objective surgeon performance metrics using a novel recorder ("dVLogger") to directly capture surgeon manipulations on the da Vinci® Surgical System. We present the initial construct and concurrent validation study of objective metrics during preselected steps of robot-assisted radical prostatectomy. Kinematic and events data were recorded for expert (100 or more cases) and novice (less than 100 cases) surgeons performing bladder mobilization, seminal vesicle dissection, anterior vesicourethral anastomosis and right pelvic lymphadenectomy. Expert/novice metrics were compared using mixed effect statistical modeling (construct validation). Expert reviewers blindly rated seminal vesicle dissection and anterior vesicourethral anastomosis using GEARS (Global Evaluative Assessment of Robotic Skills). Intraclass correlation measured inter-rater variability. Objective metrics were correlated to corresponding GEARS metrics using Spearman's test (concurrent validation). The performance of 10 experts (mean 810 cases, range 100 to 2,000) and 10 novices (mean 35 cases, range 5 to 80) was evaluated in 100 robot-assisted radical prostatectomy cases. For construct validation the experts completed operative steps faster (p <0.001) with less instrument travel distance (p <0.01), less aggregate instrument idle time (p <0.001), shorter camera path length (p<0.001) and more frequent camera movements (p <0.03). Experts had a greater ratio of dominant-to-nondominant instrument path distance for all steps (p <0.04) except anterior vesicourethral anastomosis. For concurrent validation the median experience of 3 expert reviewers was 300 cases (range 200 to 500). Intraclass correlation among reviewers was 0.6-0.7. For anterior vesicourethral anastomosis and seminal vesicle dissection, kinematic metrics had low associations with GEARS metrics. Objective metrics revealed experts to be more efficient and directed during preselected steps of robot-assisted radical prostatectomy. Objective metrics had limited associations to GEARS. These findings lay the foundation for developing standardized metrics for surgeon training and assessment.

Surgeon Performance Predicts Early Continence After Robot-Assisted Radical Prostatectomy.

There is limited, yet compelling evidence supporting the role of surgeon technical performance in influencing patient outcomes. To date, this concept has been underexplored in endourologic procedures. We hypothesized that a surgeon's technical performance plays a role in predicting an early return to continence after robot-assisted radical prostatectomy (RARP). We conducted a retrospective, matched case-control analysis of prospectively collected unedited RARP endoscopic videos performed by a single surgeon. A blinded observer with expertise in intraoperative video analysis evaluated clinically relevant steps of RARP using the global evaluative assessment of robotic skill (GEARS) and the generic error rating tool (GERT). The primary outcome was continence status at 3 months postoperatively, defined as patient use of less than or equal to a single precautionary pad. Mann-Whitney U tests examined differences in predictor variables between cases and controls, and multivariate analysis was conducted using binary logistic regression models. Twenty-four incontinent patients were matched for age, body mass index, preoperative International Prostate Symptoms Score, use of posterior/anterior hitch, prostate weight, and learning curve position. No statistically significant difference in errors between groups was observed using the GERT. On multivariate analysis, overall case GEARS score was independently predictive of 3-month continence status (odds ratios [OR] = 0.55, 95% confidence interval [CI] 0.33-0.91), as were urethrovesical anastomosis (OR = 0.70, 95% CI 0.50-0.97) and bladder neck GEARS scores (OR = 0.69, 95% CI 0.51-0.94). Our study generates the hypothesis that there may be a link between surgeon technical performance and functional outcomes in RARP. This relationship may have implications for the accreditation and training of future urologists and warrants further investigation.

Modular Training for Robot-Assisted Radical Prostatectomy: Where to Begin?

Effective training is paramount for patient safety. Modular training entails advancing through surgical steps of increasing difficulty. This study aimed to construct a modular training pathway for use in robot-assisted radical prostatectomy (RARP). It aims to identify the sequence of procedural steps that are learnt before surgeons are able to perform a full procedure without an intervention from mentor. This is a multi-institutional, prospective, observational, longitudinal study. We used a validated training tool (RARP Score). Data regarding surgeons' stage of training and progress were collected for analysis. A modular training pathway was constructed with consensus on the level of difficulty and evaluation of individual steps. We identified and recorded the sequence of steps performed by fellows during their learning curves. We included 15 urology fellows from UK, Europe, and Australia. A total of 15 surgeons were assessed by mentors in 425 RARP cases over 8 months (range: 7-79) across 15 international centers. There were substantial differences in the sequence of RARP steps according to the chronology of the procedure, difficulty level, and the order in which surgeons actually learned steps. Steps were not attempted in chronological order. The greater the difficulty, the later the cohort first undertook the step (p = 0.021). The cohort undertook steps of difficulty level I at median case number 1. Steps of difficulty levels II, III, and IV showed more variation in median case number of the first attempt. We recommend that, in the operating theater, steps be learned in order of increasing difficulty. A new modular training route has been designed. This incorporates the steps of RARP with the following order of priority: difficulty level > median case number of first attempt > most frequently undertaken in surgical training. An evidence-based modular training pathway has been developed that facilitates a safe introduction to RARP for novice surgeons.

Impact of Resident Involvement on Robot-Assisted Radical Prostatectomy Outcomes.

This study examines perioperative outcomes of resident involvement during various steps of robot-assisted radical prostatectomy (RARP). The RARP procedure was divided into seven steps: bladder takedown (BTD), endopelvic fascia, bladder neck (BN), seminal vesicle/vas deferens, pedicle/nerve sparing, apex, and anastomosis. Three hundred seventy-two RARPs performed by a single surgeon were analyzed. Resident console time during each of the seven steps was recorded. Perioperative variables were compared to surgeon-only cases. Residents performed on the console for 232 of 372 cases (62.4%). Estimated blood loss (p = 0.09), transfusion (p = 0.11), and complications (p = 0.33) were no different between surgeon-only and resident-involved cases. Mean operating room time (ORT) was less for the surgeon-only cases (190.4 vs 206.4 minutes, p = 0.003). There was no difference in positive margins (p = 0.79), length of stay (LOS) (p = 0.30), catheter days (p = 0.17), readmission (p = 0.33), or reoperation (p = 0.73) when comparing surgeon-only to resident-involved cases. Residents performing the BN step had no effect on BN margins (p = 0.73) or prolonged catheterization (p = 0.62). ORT was significantly prolonged if BTD was performed by a resident (233.0 vs 191.7 minutes, p < 0.0001). Residents performing anastomosis had no effect on prolonged catheter time (p = 0.62) or LOS (p = 0.20). Residents were more likely to be involved in at least one portion of RARP following the purchase of a Mimic simulator (Mimic Technologies, Inc., Seattle, WA) in January 2012. Supervised resident console involvement in RARP does not affect perioperative outcomes, although, it prolongs ORT, with the BTD step having the most effect on ORT.

MP11-02 IMPACT OF RESIDENT TRAINEE INVOLVEMENT ON ROBOT ASSISTED RADICAL PROSTATECTOMY (RARP) OUTCOMES.

You have accessJournal of UrologySurgical Technology & Simulation: Training & Skills Assessment I1 Apr 2016MP11-02 IMPACT OF RESIDENT TRAINEE INVOLVEMENT ON ROBOT ASSISTED RADICAL PROSTATECTOMY (RARP) OUTCOMES. Eric Schommer, Kolbi Tonkovich, Zhou Li, and David Thiel Eric SchommerEric Schommer More articles by this author , Kolbi TonkovichKolbi Tonkovich More articles by this author , Zhou LiZhou Li More articles by this author , and David ThielDavid Thiel More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.2373AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES This study examines peri-operative outcomes of RARP and their association with resident trainee involvement in different steps of RARP. METHODS RARP was divided into 7 steps: bladder takedown (BTD), endopelvic fascia, bladder neck (BN), seminal vesicle/vas deferens (sv/vas), pedicle/nerve sparing, apex, and anastomosis. 372 RARP performed by a single surgeon from July 2007 to February 2015 were analyzed. Resident console time (RCT) during each of the 7 key steps was recorded. Peri-operative variables were compared between surgeon-only (SO) and resident-involved (RI) cases. Vital outcomes of trainee performance on the key steps were compared using two sample t-test or Wilcoxon rank sum test. RESULTS Residents performed on the console for 232 of 372 cases (62.4%). Preoperative BMI (mean 28.4), PSA (mean 6.7), Gleason score (6-7 88.7%, 8-10 11.3%), ASA score (mean 2.4), AUA score (mean 8.9) and SHIM score (mean 15.9) were similar between SO and RI cases. 2nd year resident status (P <0.0001) and pre-operative PSA > 10 (P=0.0093) were associated with no RCT. Estimated blood loss (P=0.09), transfusion (P=0.11), and complications (P=.33) were no different between SO and RI cases. Mean OR time (ORT) was less for the SO cases (190.4 vs. 206.4 min, P=0.003). There was no difference in positive margins (P=0.79), length of stay (LOS) (P=0.30), catheter days (P=0.17), readmission (P=0.33), reoperation (P=0.73), home with drain (P=0.88), or undetectable 6 month PSA (P=0.07) when comparing SO to RI cases. Residents performing BN step had no effect on BN margins (P=0.73), prolonged catheterization (P=0.62), home with drain (P=0.4121), or 6 month undetectable PSA (P=0.1070). ORT was not affected by resident performing anastomosis (P=0.08) or sv/vas (P=0.82), but was significantly prolonged if BTD performed by trainee (233.0 vs. 191.7min, P <0.0001). Residents performing anastomosis had no effect on prolonged catheter time (P=0.62), home with drain (P=0.41), or LOS (P=0.20). Residents were more likely to be involved in at least one portion of the case (74.0% vs. 56.6%, P=0.0012), in BN (63.4% vs. 30.6% P <0.0001), and anastomosis (48.0% vs. 15.3%, P <0.0001) following purchase of Mimic simulator (Mimic Technologies, Inc., Seattle, WA, USA) in January 2012. CONCLUSIONS Supervised RCT in RARP does not negatively affect peri-operative patient outcomes although it prolongs ORT compared to SO cases with the BTD step adding the most operative time. The acquisition of a robotic simulator appears to have increased RCT in various steps of RARP. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e111 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Eric Schommer More articles by this author Kolbi Tonkovich More articles by this author Zhou Li More articles by this author David Thiel More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Structured and Modular Training Pathway for Robot-assisted Radical Prostatectomy (RARP): Validation of the RARP Assessment Score and Learning Curve Assessment

BackgroundUse of robot-assisted radical prostatectomy (RARP) for prostate cancer is increasing. Structured surgical training and objective assessment are critical for outcomes. ObjectiveTo develop and validate a modular training and assessment pathway via Healthcare Failure Mode and Effect Analysis (HFMEA) for trainees undertaking RARP and evaluate learning curves (LCs) for procedural steps. Design, setting, and participantsThis multi-institutional (Europe, Australia, and United States) observational prospective study used HFMEA to identify the high-risk steps of RARP. A specialist focus group enabled validation. Fifteen trainees who underwent European Association of Urology robotic surgery curriculum training performed RARP and were assessed by mentors using the tool developed. Results produced LCs for each step. A plateau above score 4 indicated competence. Outcome measurements and statistical analysisWe used a modular training and assessment tool (RARP Assessment Score) to evaluate technical skills. LCs were constructed. Multivariable Kruskal-Wallis, Mann-Whitney U, and κ coefficient analyses were used. Results and limitationsFive surgeons were observed for 42 console hours to map steps of RARP. HFMEA identified 84 failure modes and 46 potential causes with a hazard score ≥8. Content validation created the RARP Assessment Score: 17 stages and 41 steps. The RARP Assessment Score was acceptable (56.67%), feasible (96.67%), and had educational impact (100%). Fifteen robotic surgery trainees were assessed for 8 mo. In 426 RARP cases (range: 4–79), all procedural steps were attempted by trainees. Trainees were assessed with the RARP Assessment Score by their expert mentors, and LCs for individual steps were plotted. LCs demonstrated plateaus for anterior bladder neck transection (16 cases), posterior bladder neck transection (18 cases), posterior dissection (9 cases), dissection of prostatic pedicle and seminal vesicles (15 cases), and anastomosis (17 cases). Other steps did not plateau during data collection. ConclusionsThe RARP Assessment Score based on HFMEA methodology identified critical steps for focused RARP training and assessed surgeons. LCs demonstrate the experience necessary to reach a level of competence in technical skills to protect patients. Patient summaryWe developed a safety and assessment tool to gauge the technical skills of surgeons performing robot-assisted radical prostatectomy. Improvement was monitored, and measures of progress can be used in future to guide mentors when training surgeons to operate safely.

Factors predicting prolonged operative time for individual surgical steps of robot-assisted radical prostatectomy (RARP): A single surgeon's experience.

We evaluated the average time required to complete individual steps of robotic-assisted radical prostatectomy (RARP) by an expert RARP surgeon. The intent is to help establish a time-based benchmark to aim for during apprenticeship. In addition, we aimed to evaluate preoperative patient factors, which could prolong the operative time of these individual steps. We retrospectively identified 247 patients who underwent RARP, performed by an experienced robotic surgeon at our institution. Baseline patient characteristics and the duration of each step were recorded. Multivariate analysis was performed to predict factors of prolonged individual steps. In multivariable analysis, obesity was a significant predictor of prolonged operative time of: docking (odds ratio [OR] 1.96), urethral division (OR 3.13), and vesico-urethral anastomosis (VUA) (OR 2.63). Prostate volume was also a significant predictor of longer operative time in dorsal vein complex ligation (OR 1.02), bladder neck division (OR 1.03), pedicle control (OR 1.04), urethral division (OR 1.02), and VUA (OR 1.03). A prolonged bladder neck division was predicted by the presence of a median lobe (OR 5.03). Only obesity (OR 2.56) and prostate volume (OR 1.04) were predictors of a longer overall operative time. Obesity and prostate volume are powerful predictors of longer overall operative time. Furthermore, both can predict prolonged time of several individual RARP steps. The presence of a median lobe is a strong predictor of a longer bladder neck division. These factors should be taken into consideration during RARP training.

MP22-05 EVALUATION OF TECHNICAL LEARNING-CURVES FOR ROBOT ASSISTED RADICAL PROSTATECTOMY - A MULTI-INSTITUTIONAL STUDY

You have accessJournal of UrologyTechnology & Instruments: Surgical Education & Skills Assessment I1 Apr 2015MP22-05 EVALUATION OF TECHNICAL LEARNING-CURVES FOR ROBOT ASSISTED RADICAL PROSTATECTOMY - A MULTI-INSTITUTIONAL STUDY Catherine Lovegrove, Giacomo Novara, Khurshid Guru, Alex Mottrie, Ben Challacombe, Johar Raza, Henk Van der Poel, James Peabody, Rick Popert, Prokar Dasgupta, and Kamran Ahmed Catherine LovegroveCatherine Lovegrove More articles by this author , Giacomo NovaraGiacomo Novara More articles by this author , Khurshid GuruKhurshid Guru More articles by this author , Alex MottrieAlex Mottrie More articles by this author , Ben ChallacombeBen Challacombe More articles by this author , Johar RazaJohar Raza More articles by this author , Henk Van der PoelHenk Van der Poel More articles by this author , James PeabodyJames Peabody More articles by this author , Rick PopertRick Popert More articles by this author , Prokar DasguptaProkar Dasgupta More articles by this author , and Kamran AhmedKamran Ahmed More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.1017AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Use of robot-assisted radical prostatectomy (RARP) has become the current standard of care. Surgical training and its—assessment are critical in assuring optimal outcomes after robot-assisted approach towards prostatectomy. Learning curves can be used to identify learning needs and evaluate the success of training methods to ensure efficient use of resources in helping trainee surgeons achieve competence. This study aims to evaluate the technical skills of trainees by constructing learning curves for individual steps of RARP. METHODS This multi-institutional, observational, prospective study used a validated assessment score designed to examine the technical skills required for the most hazardous steps of RARP. The RARP Assessment Score was distributed to 15 trainees who performed numerous RARP cases and were scored by their mentors. Results were analysed relative to RARP experience to examine learning—curves for each step. RESULTS 15 trainees were assessed for 8 months. They participated in 426 RARP cases (Range 4–79) and, all 17 procedural steps were attempted. Of reported data, the majority of cases were T stage 2 (40.3%), N stage 0 (59.9%) and “Intermediate” D'Amico risk (36.1%). Learning curves derived demonstrated several findings. Of note were the plateaus for Anterior Bladder Neck Transection (16 cases), Posterior Bladder Neck Transection (18 cases), Posterior Dissection (9 cases), Dissection of Prostatic Pedicle and Seminal Vesicles (15 cases) and Anastomosis (17 cases). For the rest of the steps the LC did not plateau for the data collection period (e.g. Expose Prostatic Apex and Endopelvic Fascia; 31 cases, Stitching and Division of Dorsal Venous Plexus; 32 cases). CONCLUSIONS RARP Assessment Score based on HFMEA methodology identified critical hazardous steps specific to RARP and was used to assess and evaluate surgeons while performing RARP. The learning curves derived demonstrate the experience necessary to reach a level of competence in essential technical skills required to protect patient safety. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e242-e243 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Catherine Lovegrove More articles by this author Giacomo Novara More articles by this author Khurshid Guru More articles by this author Alex Mottrie More articles by this author Ben Challacombe More articles by this author Johar Raza More articles by this author Henk Van der Poel More articles by this author James Peabody More articles by this author Rick Popert More articles by this author Prokar Dasgupta More articles by this author Kamran Ahmed More articles by this author Expand All Advertisement Advertisement PDF DownloadLoading ...

Pilot Validation Study of the European Association of Urology Robotic Training Curriculum

BackgroundThe development of structured and validated training curricula is one of the current priorities in robot-assisted urological surgery. ObjectiveTo establish the feasibility, acceptability, face validity, and educational impact of a structured training curriculum for robot-assisted radical prostatectomy (RARP), and to assess improvements in performance and ability to perform RARP after completion of the curriculum. Design, setting, and participantsA 12-wk training curriculum was developed based on an expert panel discussion and used to train ten fellows from major European teaching institutions. The curriculum included: (1) e-learning, (2) 1 wk of structured simulation-based training (virtual reality synthetic, animal, and cadaveric platforms), and (3) supervised modular training for RARP. Outcome measurements and statistical analysisThe feasibility, acceptability, face validity, and educational impact were assessed using quantitative surveys. Improvement in the technical skills of participants over the training period was evaluated using the inbuilt validated assessment metrics on the da Vinci surgical simulator (dVSS). A final RARP performed by fellows on completion of their training was assessed using the Global Evaluative Assessment of Robotic Skills (GEARS) score and generic and procedure-specific scoring criteria. Results and limitationsThe median baseline experience of participants as console surgeon was 4 mo (interquartile range [IQR] 0–6.5 mo). All participants completed the curriculum and were involved in a median of 18 RARPs (IQR 14–36) during modular training. The overall score for dVSS tasks significantly increased over the training period (p<0.001-0.005). At the end of the curriculum, eight fellows (80%) were deemed able by their mentors to perform a RARP independently, safely, and effectively. At assessment of the final RARP, the participants achieved an average score ≥4 (scale 1–5) for all domains using the GEARS scale and an average score >10 (scale 4–16) for all procedural steps using a generic dedicated scoring tool. In performance comparison using this scoring tool, the experts significantly outperformed the fellows (mean score for all steps 13.6 vs 11). ConclusionsThe European robot-assisted urologic training curriculum is acceptable, valid, and effective for training in RARP. Patient summaryThis study shows that a 12-wk structured training program including simulation-based training and mentored training in the operating room allows surgeons with limited robotic experience to increase their robotic skills and their ability to perform the surgical steps of robot-assisted radical prostatectomy.

Validation of a novel, tissue-based simulator for robot-assisted radical prostatectomy.

To create a tissue-based simulator that allows practice of key steps of robot-assisted radical prostatectomy (RARP) in a sequential fashion. A model was created from female porcine genitourinary tract tissue to represent the male pelvic genitourinary anatomy. The following steps of RARP were simulated: dorsal venous complex ligation, division of bladder neck, seminal vesicle dissection, prostatic pedicle ligation with nerve sparing, urethral division, bladder neck reconstruction, and vesicourethral anastomosis. Ten novices and 10 experts performed RARP on the model. Face validity was calculated by ratings of realism. Content validity was calculated by experts' rating of usefulness of the model as a training tool. Construct validity was calculated by comparison of time to complete the simulator and rating of performance on the objective structured assessment of technical skill (OSATS) questionnaire, between novices and experts. The model was determined to have good face and content validity with an average score of 3.7/5 and 4.8/5, respectively. The mean time for completion of the simulator was 121.5 minutes for the novice and 62 minutes for the expert group (P<0.001), and the mean overall OSATS performance ratings were 4.6/5 for experts and 2.6/5 for novices (P<0.001), yielding good construct validity. We created and validated a realistic, tissue-based simulator to allow for training of key surgical steps of RARP in a sequential fashion. Ultimately, this simulator could be incorporated into urology training, credentialing, and facilitate surgeon transitioning from open prostatectomy to RARP.

MP58-01 MULTI-INSTITUTIONAL VALIDATION OF THE ERUS ROBOTIC SURGERY TRAINING CURRICULUM

You have accessJournal of UrologyProstate Cancer: Localized VI1 Apr 2014MP58-01 MULTI-INSTITUTIONAL VALIDATION OF THE ERUS ROBOTIC SURGERY TRAINING CURRICULUM Alessandro Volpe, Kamran Ahmed, Prokar Dasgupta, Vincenzo Ficarra, Henk Van der Poel, Alexandre Mottrie, and ERUS board members Alessandro VolpeAlessandro Volpe More articles by this author , Kamran AhmedKamran Ahmed More articles by this author , Prokar DasguptaProkar Dasgupta More articles by this author , Vincenzo FicarraVincenzo Ficarra More articles by this author , Henk Van der PoelHenk Van der Poel More articles by this author , Alexandre MottrieAlexandre Mottrie More articles by this author , and ERUS board members ERUS board members More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2014.02.1817AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The criteria set for surgeon’s competence before starting robotic surgery are neither structured nor evidence based. The development of structured and validated training curricula represents one of the current priorities in the robotic urologic field. METHODS A 12-weeks structured training program/curriculum was developed based on a focused group expert panel discussion and used to train 10 fellows from major teaching institutions across Europe. The key components of the curriculum were e-learning, an intensive week of structured simulation laboratory training (virtual reality simulator and dry/wet lab simulation platforms) and modular training in robot-assisted radical prostatectomy (RARP) at each institutions under supervision of the mentors. The technical and non- technical skills of the fellows were assessed by the mentors at the end of the program using previously validated GEARS (score 1- 5) and NOTTS (score 1-4) scales. At the end of the training, a full RARP performed by the fellows was video-recorded and blindly assessed by two independent expert robotic surgeons using a dedicated assessment scale. The scores of the fellows were compared with those of two expert robotic surgeons. The educational impact was evaluated with a dedicated questionnaire. RESULTS The fellows had limited previous console exposure (4 mos, IQR 0-6.5). At the end of the training, the fellows received an average score >4 (4.1-4.7) from their mentors for all the technical skills domains of the GEARS scale, with no negative scores (≤2). An average score ≥3.5 was also achieved for the 4 non-technical skills domains of the NOTTS scale, with no negative scores (≤2). Eight fellows were deemed able to perform a RARP alone by their mentors. At the assessment of the video-recorded RARP, 6 fellows received a sufficient score by the reviewers for all steps of the surgical procedure and 8 reached an average overall sufficient score. The robotic experts significantly outperformed the fellows for all surgical steps. At the final questionnaire, all fellows considered the program effective in improving their robotic skills and ability to perform the surgical steps of RARP with a mean score of 4.7 on a Likert-type scale (1=strongly disagree to 5=strongly agree). CONCLUSIONS This 12-weeks structured training program was successful to improve the robotic skills of fellows and their ability to perform the surgical steps of RARP. Further studies are needed to define the ideal length and schedule of these programs. This pilot study represents a step towards the definition of validated curricula for RARP and other robotic procedures. © 2014FiguresReferencesRelatedDetails Volume 191Issue 4SApril 2014Page: e658 Advertisement Copyright & Permissions© 2014MetricsAuthor Information Alessandro Volpe More articles by this author Kamran Ahmed More articles by this author Prokar Dasgupta More articles by this author Vincenzo Ficarra More articles by this author Henk Van der Poel More articles by this author Alexandre Mottrie More articles by this author ERUS board members More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Approach to the Bladder Neck During Robot-Assisted Radical Prostatectomy

Introduction: Dissection of the bladder neck represents one of the most challenging steps of robot-assisted radical prostatectomy, particularly in the presence of difficult anatomic conditions. These can be natural, such as the presence of a median lobe, or due to previous surgery, as in the case of previous surgery for benign prostatic hyperplasia. Materials and Methods: A standardized approach to the bladder neck was applied to robot-assisted radical prostatectomy performed with the Da Vinci Surgical System. Results: A 30° camera is used during the bladder neck dissection. The line of dissection of the anterior bladder neck can be identified operating traction with the fourth arm, with a symmetric pressure of the robotic arms or pulling the catheter. The use of a low monopolar energy helps in maintaining the features of the tissue, thus distinguishing the muscular tissue of the detrusor from the glandular tissue of the prostate. The approach to the posterior bladder neck is based on two opposite tractions: that on the catheter superiorly and that on the bladder neck inferiorly. The incision begins on the lateral aspects of the detrusor. After releasing the lateral muscular fibers, and so transferring the traction on the midline, the bladder neck is dissected. A constant traction is made by means of the left arm; the scissors, with separate blades, develop the surgical plane, until the seminal vesicles are visible. The assistant can help providing downward traction with the sucker. In the presence of a median lobe, traction on the catheter can help identifying an eventual asymmetry of the lobes. The dissection of the anterior bladder neck begins again on the midline, until the catheter is identified and suspended. The lateral aspects of the detrusor are separated, while traction is exerted with the left arm. When the median lobe becomes evident, the point of traction is changed to the median lobe itself to improve exposition, while the assistant can help again providing downward traction. We do not use stitches on the median lobe for counter traction. Special attention should be given to the thickness of the posterior aspect of the bladder neck and to identification of the ureteral orifices. The bladder neck defect after transurethral resection of prostate (TURP) can create many difficulties in the dissection. The catheter is pulled cranially and superiorly, exposing the large defect of the bladder neck. Here is even more important to separate the lateral aspects before dissection of the posterior bladder neck. The presence of scar tissue can make it more difficult to distinguish the muscular from the glandular tissue. When the bladder neck results are large, we perform bilateral plication over the lateral aspects of the bladder using sutures of 3-0 poliglecaprone, 13 cm long, in an RB-1 needle, as described by Lin et al.1 Conclusions: A standardized approach to the bladder neck can be implied even in the presence of difficult anatomical conditions. No competing financial interests exist. Runtime of video: 7 mins

Initial experience of teaching robot‐assisted radical prostatectomy to surgeons‐in‐training: can training be evaluated and standardized?

To measure the time and subjective quality of individual steps of robot-assisted radical prostatectomy (RARP), as RARP performed by trainees has recently become the most common technique of RP in the USA, and although outcomes from expert surgeons are reported, limited data are available to document training experiences. The patients studied were from a prospective cohort of 178 participants (124 with training data). Transperitoneal RARP was performed by one faculty surgeon and one assistant from a rotation of four urological oncology fellows and three residents. RARP was divided into 11 steps, and staff times were recorded for each step. Trainee times and quality scores were recorded for each step, the later defined as grade A equal to staff (A+, no verbal coaching); B, minor corrections; and C, major corrections. Short-term outcomes were recorded to assess the safety of the training. The mean (range) console time/case of trainees was 40 (10-123) min. The median console time for a complete case by faculty and by trainees (pooled group) was 128 and 231 min, respectively, an increase in 81%. Individual trainee-performed steps increased in time (compared to staff) by a median range of 50-177%, and the incidence of quality grades < A of 9-100%. Trainee quality grades for basic tissue-dissection steps were higher than for advanced tissue dissection and suturing. There was no downgrading for a major correction. Analysis of short-term outcomes suggested acceptable results in a training environment. The study is limited by no available validated training measurement tools, and a low frequency of beginner trainees advancing to more difficult steps during the rotation. During the initial exposure of trainees to RARP of <40 cases, we measured time and subjective quality grading of basic steps, and introduction to advanced steps. Training requires more procedure time, but does not appear to diminish expected outcomes.