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Daykan Y, Farinha R, Schraffordt SE, Mottrie A, O'Reilly BA. A cost-effective model for training in Robot-Assisted Sacrocolpopexy. Int Urogynecol J 2023; 34:3059-3062. [PMID: 37453031 DOI: 10.1007/s00192-023-05604-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 06/25/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND The number of robotically assisted sacrocolpopexy procedures are increasing; therefore, experienced clinicians are needed. Simulation-based cadaver models are challenging in aspects of cost and availability. Therefore, we need to look at alternative and more cost-effective models. OBJECTIVE The objective of this video was to design a new surgical model for the training of robotic-assisted sacrocolpopexy, which is affordable and accessible. METHODS We used a whole chicken model to simulate the female pelvic floor. We used Medtronic's Hugo™ RAS system as the robotic console in that procedure. A vaginal cuff was prepared from the proventriculus (stomach), and a Y shaped mesh was secured to the ischium to simulate the sacrocolpopexy procedure. CONCLUSION This model is easily constructed and in our view is cost-effective. We have demonstrated a new valuable education tool that can serve as a practical simulation model to teach the sacrocolpopexy procedure and to improve trainees' skills. A larger cohort study size is essential to demonstrate the learning curve among young trainees using this simulation model.
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Affiliation(s)
- Yair Daykan
- Department of Urogynaecology, Cork University Maternity Hospital, Cork, Ireland.
- Department of Obstetrics and Gynecology, Meir Medical Center, Kfar Saba, Israel, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Rui Farinha
- Department of Urology, OLV, Aalst, Belgium
- ORSI Academy, Melle, Belgium
| | | | - Alexander Mottrie
- Department of Urology, OLV, Aalst, Belgium
- ORSI Academy, Melle, Belgium
| | - Barry A O'Reilly
- Department of Urogynaecology, Cork University Maternity Hospital, Cork, Ireland
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Baker MV, Teles Abrao Trad A, Tamhane P, Weaver AL, Visscher SL, Borah BJ, Klingele CJ, Gebhart JB, Trabuco EC. Abdominal and robotic sacrocolpopexy costs following implementation of enhanced recovery after surgery. Int J Gynaecol Obstet 2022; 161:655-660. [PMID: 36504261 DOI: 10.1002/ijgo.14623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 11/04/2022] [Accepted: 12/07/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To compare perioperative costs and morbidity between open and robotic sacrocolpopexy after implementation of enhanced recovery after surgery (ERAS) pathway. METHODS The present retrospective cohort study of patients undergoing open or robotic sacrocolpopexy (January 1, 2014, through November 30, 2017) used an ERAS protocol with liposomal bupivacaine infiltration of laparotomy incisions. Primary outcomes were costs associated with index surgery and hospitalization, determined with Medicare cost-to-charge ratios and reimbursement rates and adjusted for variables expected to impact costs. Secondary outcomes included narcotic use, length of stay (LOS), and complications from index hospitalization to postoperative day 30. RESULTS For the total of 231 patients (open cohort, 90; robotic cohort, 141), the adjusted mean cost of robotic surgery was $3239 higher compared with open sacrocolpopexy (95% confidence interval [CI] $1331-$5147; P < 0.001). Rates were not significantly different for intraoperative complications (robotic, 4.3% [6/141]; open, 5.6% [5/90]; P = 0.754), 30-day postoperative complications (robotic, 11.4% [16/141]; open, 16.7% [15/90]; P = 0.322), or readmissions (robotic, 5.7% [8/141]; open, 3.3% [3/90]; P = 0.535). The percentage of patients dismissed on postoperative day 1 was greater in the robotic group (89.4% [126/141] vs. 48.9% [44/90], P < 0.001). CONCLUSIONS Decreased LOS associated with ERAS provided significant cost savings with open sacrocolpopexy versus robotic sacrocolpopexy without adverse impacts on perioperative complications or readmissions.
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Affiliation(s)
- Mary V Baker
- Department of Obstetrics and Gynecology, Mayo Clinic School of Graduate Medical Education, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
| | - Ayssa Teles Abrao Trad
- Department of Obstetrics and Gynecology, Mayo Clinic School of Graduate Medical Education, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
| | - Prajakta Tamhane
- Department of Family Medicine, Reid Health, Richmond, Indiana, USA
| | - Amy L Weaver
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota, USA
| | - Sue L Visscher
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA
| | - Bijan J Borah
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota, USA.,Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota, USA.,Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - John B Gebhart
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota, USA
| | - Emanuel C Trabuco
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota, USA
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Sassani JC, Clark SG, McGough CE, Shepherd JP, Bonidie M. Sacrocolpopexy experience with a novel robotic surgical platform. Int Urogynecol J 2022; 33:3255-3260. [PMID: 35312804 DOI: 10.1007/s00192-022-05155-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 02/20/2022] [Indexed: 12/01/2022]
Abstract
INTRODUCTION AND HYPOTHESIS The objective was to describe early experience performing sacrocolpopexy using a novel robotic surgical platform. METHODS This is a case series of all women who underwent robotic-assisted sacrocolpopexy using a new robotics platform (TransEnterix Senhance) between January 2019 and July 2021. All sacrocolpopexies were performed by a single Female Pelvic Medicine and Reconstructive surgeon at a large academic institution. Perioperative information including complications was abstracted from the medical record. Anatomical recurrence was defined as any anatomical point at or past the hymen (≥0). Data are descriptive, with Mann-Whitney U test used for comparison of operative time between the first and second half of the patients. RESULTS A total of 25 sacrocolpopexies were performed using the new robotics platform. Mean age was 62.3 years (±9.2) and mean BMI was 26.5 (±3.8). Ten (40.0%) patients had a prior hysterectomy. Most (n = 21, 84.0%) had stage III or IV prolapse preoperatively. Mean operative time was 210.2 min (±48.6) and median estimated blood loss was 35 ml (IQR 25-50). Mean operative time decreased between the first and second half of the patients (231.7 min vs 190.3 min, p = 0.047). There were no major intraoperative complications. Median follow-up time was 16 weeks (IQR 4-34) and there were no subjective recurrences or retreatments during this period. Two patients (8.0%) had anatomical recurrence without subjective bother. There were two postoperative readmissions (8.0%) within 30 days for small bowel obstruction, one treated surgically and the other with nonsurgical management. CONCLUSIONS Our case series demonstrates feasibility and successful early adoption of a new robotics platform for robotic sacrocolpopexy.
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Affiliation(s)
- Jessica C Sassani
- Division of Urogynecology, Department of Obstetrics, Gynecology & Reproductive Sciences, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
| | - Stephanie Glass Clark
- Division of Urogynecology, Department of Obstetrics, Gynecology & Reproductive Sciences, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Christine E McGough
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Jonathan P Shepherd
- Department of Obstetrics & Gynecology, University of Connecticut Health Center, Farmington, CT, USA
| | - Michael Bonidie
- Division of Urogynecology, Department of Obstetrics, Gynecology & Reproductive Sciences, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Giannini A, Russo E, Misasi G, Falcone M, Caretto M, Morganti R, Mannella P, Simoncini T. Technical features, perioperative and anatomical outcomes of a standardized suturing pattern for robotic sacrocolpopexy. Int Urogynecol J 2022; 33:3085-3092. [PMID: 35037972 DOI: 10.1007/s00192-021-05049-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Accepted: 11/13/2021] [Indexed: 11/30/2022]
Abstract
INTRODUCTION AND HYPOTHESIS Several technical alternatives to repair mesh using laparoscopic sacrocolpopexy exist. We aim to describe the outcomes and surgical technique of robotic-assisted colpo-/cervicosacropexy using a standardized suturing scheme to repair the mesh. METHODS We retrospectively reported data of 60 consecutive cases of robotic-assisted colpo-/cervicosacropexy for advanced multicompartmental prolapse using a standardized suturing design. We placed three non-absorbable stitches on the cervix or three absorbable stitches on the apex of the vaginal vault, six long-term absorbable stitches on the anterior vaginal wall deep to the basis of the vesical trigone, six similar posterior stitches with the deeper row of sutures down to the levator ani plane and three non-absorbable stitches on the sacral promontory as the cranial support for Y-shaped polypropylene mesh. RESULTS Median operative time was 188 ± 43 min. All the procedures were successfully performed using a Da Vinci Si platform in a three-arm configuration, and no conversion to open or traditional laparoscopic surgery was needed. The length of hospital stay was 1.2 ± 1.7 days, and no readmission within 30 postoperative days was reported. At a follow-up of 12 and 24 months, no case of extrusion or exposure of the mesh occurred, and the retreatment rate was 6.7%. CONCLUSIONS Our suturing technique is safe and effective, with negligible risk of complications and good medium-term results. It is plausible that robotic systems may facilitate precise, accurate and reproducible placement of the stitches, thereby favoring wider diffusion of minimally invasive treatment of advanced prolapse.
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Affiliation(s)
- Andrea Giannini
- Department of Clinical and Experimental Medicine, Division of Obstetrics and Gynecology, University of Pisa, Via Roma, 67, 56126, Pisa, Italy.
| | - Eleonora Russo
- Department of Clinical and Experimental Medicine, Division of Obstetrics and Gynecology, University of Pisa, Via Roma, 67, 56126, Pisa, Italy
| | - Giulia Misasi
- Department of Clinical and Experimental Medicine, Division of Obstetrics and Gynecology, University of Pisa, Via Roma, 67, 56126, Pisa, Italy
| | - Maria Falcone
- Department of Clinical and Experimental Medicine, Division of Obstetrics and Gynecology, University of Pisa, Via Roma, 67, 56126, Pisa, Italy
| | - Marta Caretto
- Department of Clinical and Experimental Medicine, Division of Obstetrics and Gynecology, University of Pisa, Via Roma, 67, 56126, Pisa, Italy
| | - Riccardo Morganti
- Department of Clinical and Experimental Medicine, Division of Obstetrics and Gynecology, University of Pisa, Via Roma, 67, 56126, Pisa, Italy
| | - Paolo Mannella
- Department of Clinical and Experimental Medicine, Division of Obstetrics and Gynecology, University of Pisa, Via Roma, 67, 56126, Pisa, Italy
| | - Tommaso Simoncini
- Department of Clinical and Experimental Medicine, Division of Obstetrics and Gynecology, University of Pisa, Via Roma, 67, 56126, Pisa, Italy
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Abstract
OBJECTIVE We sought to validate a simulation model for robotic sacrocolpopexy (RSCP) that includes multiple steps: presacral dissection/mesh attachment, vaginal mesh attachment, and peritoneal closure. METHODS An RSCP training model was developed. Female pelvic medicine and reconstructive surgery (FPMRS) experts and current FPMRS fellows were videotaped using the model; sessions were timed and scored using the Global Evaluative Assessment of Robotic Skills (GEARS) by 3 surgeon reviewers masked to participants' identities. Construct validity was measured by comparing performance on the model between experts and trainees. Interrater reliability was determined by calculating intraclass correlation coefficients for total GEARS scores. Face validity was assessed by a postprocedure questionnaire. RESULTS Experts included 9 board-certified FPMRS physicians experienced in RSCP; trainees were 17 fellows. Experts practiced at 7 different institutions in the United States, and the majority (5/7) taught fellows. Trainees were from 7 institutions and in various years of training: postgraduate year (PGY) 5 (n = 6), PGY 6 (n = 5), and PGY 7 (n = 6). Experts' performances were rated significantly higher for total GEARS scores and for relevant domains of the GEARS scale. Intraclass correlation coefficient for the 3 reviewer pairs (0.96-0.99) indicated high interrater reliability. All participants "agreed/strongly agreed" that the model closely approximated live RSCP surgery and was useful for teaching and learning the procedure, indicating high face validity. CONCLUSIONS This novel, multistep simulation model demonstrated construct validity and high interrater reliability. Face validity was also established. Consequently, this RSCP model could be used for surgical training and assessment of these discrete surgical skill steps.
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Laparoscopic Pectopexy-CUSUM Learning Curve and Perioperative Complications Analysis. J Clin Med 2021; 10:jcm10051052. [PMID: 33806294 PMCID: PMC7961615 DOI: 10.3390/jcm10051052] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 02/20/2021] [Accepted: 03/01/2021] [Indexed: 12/14/2022] Open
Abstract
The study aimed to examine the learning curve and perioperative complications for laparoscopic pectopexy (LP). A total of 60 women with stage II–IV apical prolapse who underwent LP were dichotomized into groups: LSH(+) with concomitant laparoscopic supracervical hysterectomy (LSH), LSH(−) after previous supracervical/total hysterectomy. Operative time, estimated blood loss and hospitalization length were evaluated with cumulative sum (CUSUM) analysis and the Kwiatkowski–Phillips–Schmidt–Shin (KPSS) test, separately for two surgeons (A and B). Intraoperative and perioperative complications according to the Clavien–Dindo (C–D) classification were analyzed. Mean operative time, change in hemoglobin level, and postoperative hospital stay were 143.5 ± 23.1 min—1.5 ± 0.5g/dL and 2.5 ± 0.9 days, respectively. LSH during pectopexy was associated with longer operative time (p = 0.01) but not with higher intraoperative bleeding or prolonged hospital stay. Severe complications rate was low (1.7%) with one bowel injury in LSH(−) (C–D grade IIIb). No C–D grade II, IV and V complications were found. Conversion to open pectopexy, return to the operating room or blood transfusion were not required. The KPSS test showed that a steady operative time for Surgeon A was achieved after 28 procedures. A proficiency for laparoscopic pectopexy based on CUSUM analysis was observed after 38–40 procedures.
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Capmas P, Suarthana E, Larouche M. Conversion rate of laparoscopic or robotic to open sacrocolpopexy: are there associated factors and complications? Int Urogynecol J 2020; 32:2249-2256. [PMID: 33104825 DOI: 10.1007/s00192-020-04570-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Accepted: 10/14/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To evaluate the conversion rate of laparoscopic or robotic to open sacrocolpopexy and to identify associated factors in a large population-based database. METHODS We used Health Care Cost and Utilization Project-National Inpatient Sample (HCUP-NIS) databases 2005-2014. We extracted data on apical suspension and synthetic mesh with laparoscopy or robot in adult women using International Classification of Diseases, ninth edition, Clinical Modification (ICD-9-CM) codes. We evaluated the rate of conversion and used logistic regression to study the association with risk factors. RESULTS We identified 3295 women with laparoscopic or robotic sacrocolpopexies. There were 2777 robotic procedures with 37 conversion (1.33%) and 518 laparoscopic procedures with 37 conversions (7.14%), with an overall conversion rate of 2.2%. Median age was 62 years [interquartile range (IQR) = 55-69]. Concomitant hysterectomy was significantly more frequent in the robotic than laparascopic group (41.7% versus 13.9%, p < 0.01) and was not associated with conversion. Factors associated with lower conversion included a robotic approach (adjusted odd ratio (aOR) 0.32 [95% CI 0.19-0.54]) and private insurance (aOR 0.53 [95% CI 0.32-0.86]). Factors associated with higher conversion were obesity (aOR 3.27 [95% CI 1.72-6.19]) and lysis of adhesions (aOR 3.32 [95% CI 1.89-5.85]). Accidental organ puncture was significantly associated with conversion (14.9% versus 3.8%; p < 0.01). CONCLUSION In this American database, the rate of conversion of laparoscopic or robotic to open sacrocolpopexy was low. The majority (84%) of minimally invasive sacrocolpopexies used a robotic approach, which was associated with a lower risk of conversion. Obesity and lysis of adhesions were associated with a higher risk of conversion.
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Affiliation(s)
- Perrine Capmas
- Department of Obstetrics and Gynecology, McGill University, Montreal, QC, Canada. .,Inserm, Centre of Research in Epidemiology and Population Health (CESP), U1018, and Faculty of Medicine, University Paris Sud, 94276, Le Kremlin Bicêtre, France.
| | - Eva Suarthana
- Department of Obstetrics and Gynecology, McGill University, Montreal, QC, Canada
| | - Maryse Larouche
- Department of Obstetrics and Gynecology, McGill University, Montreal, QC, Canada
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Harmanli O, Solak S, Bayram A, Yuksel B, Jones K. Optimizing the robotic surgery team: an operations management perspective. Int Urogynecol J 2020; 32:1379-1385. [PMID: 32902765 DOI: 10.1007/s00192-020-04527-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 08/31/2020] [Indexed: 11/28/2022]
Abstract
INTRODUCTION AND HYPOTHESIS To assess the critical threshold to optimize operating room (OR) time for each surgical team member in robotically assisted sacrocolpopexy (RASCP) and to evaluate the most efficient team compositions. METHODS All women who underwent RASCP for pelvic organ prolapse (POP) were prospectively entered in a database. Patients having unrelated concomitant surgery were excluded. Our primary outcome measure was total OR time. We utilized factor analysis, regression analysis, and analysis of variance, OR time mapping, and stochastic optimization to identify 'optimal' surgical team configuration. RESULTS The database included 359 consecutive RASCPs, all performed for stage III-IV POP: 156 (43%) were with total and 44 (12%) supracervical hysterectomies and 159 (44%) post-hysterectomy. Mean age was 58.6 ± 9.3 years. Mean parity was 2.8 ± 1.4, and mean body mass index was 28 ± 4.7 kg/m2. A total of 4 surgeons, 34 first assistants, 20 circulating nurses, 15 surgical technologists, and 59 anesthesiologist/nurse anesthetists were involved. Optimal experience levels for each team member were achieved at the following number of robotic procedures: surgeon 44; first assistant 13; surgical technologist 66; circulating nurse 56; anesthesia provider 46. Our analysis revealed that the surgical technologist and first assistant played the most significant roles within the team. The surgeon was ranked third followed by the circulating nurse and anesthesia provider, respectively. CONCLUSION Operating time in robotic surgery is multifactorial. Experience of each member of a robotic surgery team is critical. An optimal team can be composed of a variety of combinations of experience levels among the robotic team members.
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Affiliation(s)
- Oz Harmanli
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale University Yale School of Medicine, New Haven, CT, USA.
| | - Senay Solak
- University of Massachusetts Isenberg School of Management, Amherst, MA, USA
| | - Armagan Bayram
- Industrial and Manufacturing Systems Engineering, University of Michigan Dearborn, Dearborn, MI, USA
| | - Beril Yuksel
- Department of Obstetrics and Gynecology, University of Massachusetts Medical School-Baystate, Springfield, MA, USA
| | - Keisha Jones
- Department of Obstetrics and Gynecology, University of Massachusetts Medical School-Baystate, Springfield, MA, USA
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Sun B, Wu H, Xu Z, Lu J, Wang Y, Zhang K, Gao X, Shen X, Wu XD, Zhang Y, Gu X, Shi C, Yuan W. Is selective nerve root block necessary for learning percutaneous endoscopic lumbar discectomy: a comparative study using a cumulative summation test for learning curve. INTERNATIONAL ORTHOPAEDICS 2020; 44:1367-1374. [PMID: 32367234 DOI: 10.1007/s00264-020-04558-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Accepted: 03/30/2020] [Indexed: 11/30/2022]
Abstract
PURPOSE The aim of this study was to investigate the effect of lumbar spine selective nerve root block (SNRB) experience on the learning efficiency of percutaneous endoscopic lumbar discectomy (PELD) for junior trainees. METHODS A total of 480 patients undergoing single-level PELD performed by eight junior trainees were included. The trainees were divided into two groups based on whether they had previous SNRB experience (group A, yes; group B, no). Surgical proficiency was defined as total operation time less than 65 minutes and cumulative radiation exposure time no more than 40 seconds. The learning curve was analyzed by cumulative summation (CUSUM) test. Clinical evaluations included Macnab classification, visual analog scale (VAS)-low back score, VAS-leg score, and Oswestry Disability Index (ODI). Follow-up information at 12 months was also obtained. RESULTS Integral number of cases before achieving an acceptable surgical level in group A (47.75 ± 2.50 cases) was significantly smaller than that in group B (56.50 ± 1.29 cases, p < 0.05), along with less accumulated failure (18.75 ± 0.96 cases vs. 25.50 ± 1.75 cases, p < 0.05). The two groups were comparable in clinical outcomes. Forty-seven cases of complications were observed, with 17 in group A and 30 in group B (p < 0.05). CONCLUSION Previous experience of SNRB improved the performance of PELD with shorter operation time and less radiation exposure. SNRB practice may reduce the complication rate without a significant effect on the recurrence of symptoms and reoperation.
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Affiliation(s)
- Bin Sun
- Department of Orthopaedics, Changzheng Hospital, Second Military Medical University, 415 Fengyang Road, Shanghai, 200003, People's Republic of China
| | - Huiqiao Wu
- Department of Orthopaedics, Changzheng Hospital, Second Military Medical University, 415 Fengyang Road, Shanghai, 200003, People's Republic of China
| | - Zeng Xu
- Department of Orthopaedics, Changzheng Hospital, Second Military Medical University, 415 Fengyang Road, Shanghai, 200003, People's Republic of China
| | - Jiajia Lu
- Department of Orthopaedics, Changzheng Hospital, Second Military Medical University, 415 Fengyang Road, Shanghai, 200003, People's Republic of China
| | - Yunhao Wang
- Department of Orthopaedics, Changzheng Hospital, Second Military Medical University, 415 Fengyang Road, Shanghai, 200003, People's Republic of China
| | - Ke Zhang
- Department of Orthopaedics, Changzheng Hospital, Second Military Medical University, 415 Fengyang Road, Shanghai, 200003, People's Republic of China
| | - Xiaoxiang Gao
- Department of Orthopaedics, The 455th Hospital of Chinese People's Liberation Army, Shanghai, China
| | - Xiaolong Shen
- Department of Orthopaedics, Changzheng Hospital, Second Military Medical University, 415 Fengyang Road, Shanghai, 200003, People's Republic of China
| | - Xiao-Dong Wu
- Department of Orthopaedics, Changzheng Hospital, Second Military Medical University, 415 Fengyang Road, Shanghai, 200003, People's Republic of China
| | - Ying Zhang
- Department of Orthopaedics, Changzheng Hospital, Second Military Medical University, 415 Fengyang Road, Shanghai, 200003, People's Republic of China
| | - Xin Gu
- Department of Orthopaedics, Changzheng Hospital, Second Military Medical University, 415 Fengyang Road, Shanghai, 200003, People's Republic of China.
| | - Changgui Shi
- Department of Orthopaedics, Changzheng Hospital, Second Military Medical University, 415 Fengyang Road, Shanghai, 200003, People's Republic of China.
| | - Wen Yuan
- Department of Orthopaedics, Changzheng Hospital, Second Military Medical University, 415 Fengyang Road, Shanghai, 200003, People's Republic of China
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Soomro NA, Hashimoto DA, Porteous AJ, Ridley CJA, Marsh WJ, Ditto R, Roy S. Systematic review of learning curves in robot-assisted surgery. BJS Open 2019; 4:27-44. [PMID: 32011823 PMCID: PMC6996634 DOI: 10.1002/bjs5.50235] [Citation(s) in RCA: 77] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Accepted: 10/03/2019] [Indexed: 12/22/2022] Open
Abstract
Background Increased uptake of robotic surgery has led to interest in learning curves for robot‐assisted procedures. Learning curves, however, are often poorly defined. This systematic review was conducted to identify the available evidence investigating surgeon learning curves in robot‐assisted surgery. Methods MEDLINE, Embase and the Cochrane Library were searched in February 2018, in accordance with PRISMA guidelines, alongside hand searches of key congresses and existing reviews. Eligible articles were those assessing learning curves associated with robot‐assisted surgery in patients. Results Searches identified 2316 records, of which 68 met the eligibility criteria, reporting on 68 unique studies. Of these, 49 assessed learning curves based on patient data across ten surgical specialties. All 49 were observational, largely single‐arm (35 of 49, 71 per cent) and included few surgeons. Learning curves exhibited substantial heterogeneity, varying between procedures, studies and metrics. Standards of reporting were generally poor, with only 17 of 49 (35 per cent) quantifying previous experience. Methods used to assess the learning curve were heterogeneous, often lacking statistical validation and using ambiguous terminology. Conclusion Learning curve estimates were subject to considerable uncertainty. Robust evidence was lacking, owing to limitations in study design, frequent reporting gaps and substantial heterogeneity in the methods used to assess learning curves. The opportunity remains for the establishment of optimal quantitative methods for the assessment of learning curves, to inform surgical training programmes and improve patient outcomes.
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Affiliation(s)
- N A Soomro
- Newcastle Upon Tyne Hospitals NHS Foundation Trust and Newcastle University, Newcastle upon Tyne, UK
| | - D A Hashimoto
- Surgical Artificial Intelligence and Innovation Laboratory, Department of Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | | | | | | | - R Ditto
- Ethicon, Blue Ash, Ohio, USA
| | - S Roy
- Ethicon, Blue Ash, Ohio, USA
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van Zanten F, Schraffordt Koops SE, Pasker-De Jong PC, Lenters E, Schreuder HW. Learning curve of robot-assisted laparoscopic sacrocolpo(recto)pexy: a cumulative sum analysis. Am J Obstet Gynecol 2019; 221:483.e1-483.e11. [PMID: 31152711 DOI: 10.1016/j.ajog.2019.05.037] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Revised: 05/15/2019] [Accepted: 05/23/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND Determination of the learning curve of new techniques is essential to improve safety and efficiency. Limited information is available regarding learning curves in robot-assisted laparoscopic pelvic floor surgery. OBJECTIVE The purpose of this study was to assess the learning curve in robot-assisted laparoscopic pelvic floor surgery. STUDY DESIGN We conducted a prospective cohort study. Consecutive patients who underwent robot-assisted laparoscopic sacrocolpopexy or sacrocolporectopexy were included (n=372). Patients were treated in a teaching hospital with a tertiary referral function for gynecologic/multicompartment prolapse. Procedures were performed by 2 experienced conventional laparoscopic surgeons (surgeons A and B). Baseline demographics were scored per groups of 25 consecutive patients. The primary outcome was the determination of proficiency, which was based on intraoperative complications. Cumulative sum control chart analysis allowed us to detect small shifts in a surgeon's performance. Proficiency was obtained when the first acceptable boundary line of cumulative sum control chart analysis was crossed. Secondary outcomes that were examined were shortening and/or stabilization of surgery time (measured with the use of cumulative sum control chart analysis and the moving average method). RESULTS Surgeon A performed 242 surgeries; surgeon B performed 137 surgeries (n=7 surgeries were performed by both surgeons). Intraoperative complications occurred in 1.9% of the procedures. The learning curve never fell below the unacceptable failure limits and stabilized after 23 of 41 cases. Proficiency was obtained after 78 cases for both surgeons. Surgery time decreased after 24-29 cases in robot-assisted sacrocolpopexy (no distinct pattern for robot-assisted sacrocolporectopexy). Limitations were the inclusion of 2 interventions and concomitant procedures, which limited homogeneity. Furthermore, analyses treated all complications in cumulative sum as equal weight, although there are differences in the clinical relevance of complications. CONCLUSION After 78 cases, proficiency was obtained. After 24-29 cases, surgery time stabilized for robot-assisted sacrocolpopexy. In this age of rapidly changing surgical techniques, it can be difficult to determine the learning curve of each procedure. Cumulative sum control chart analysis can assist with this determination and prove to be a valuable tool. Training programs could be individualized to improve both surgical performance and patient benefits.
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Kasabwala K, Goueli R, Culligan PJ. A live porcine model for robotic sacrocolpopexy training. Int Urogynecol J 2019; 30:1371-1375. [PMID: 31055610 DOI: 10.1007/s00192-019-03936-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Accepted: 03/14/2019] [Indexed: 12/01/2022]
Abstract
INTRODUCTION AND HYPOTHESIS Robotic sacrocolpopexy is an effective and durable technique for pelvic organ prolapse repair. However, the learning curve for this procedure has underscored the need for an effective surgical training module. Given the cost, infection risk, poor tissue compliance, and scarcity of human cadavers, the live porcine model represents a realistic, available, and cost-effective alternative. This article describes a live porcine model for teaching robotic sacrocolpopexy to determine whether it teaches key aspects of live human robotic sacrocolpopexy to the learner. METHODS This robotic sacrocolpopexy model was created using the Da Vinci Xi or Si robotic system on domestic pigs under general anesthesia. The main steps of the model include: (1) creating the porcine "cervix" and (2) performing robotic sacrocolpopexy. The model was evaluated with a survey given to 18 board-certified surgeons who attended the training course between December 2016 and April 2018. RESULTS All of the participants reported improvements in their economy of motion, tissue handling ability, suturing efficiency, and overall performance of robotic sacrocolpopexy. Furthermore, a majority of participants were likely to incorporate aspects of the model into their practice (88.8%) and recommend the model to colleagues (94.2%). CONCLUSIONS The porcine model provides a feasible tool for teaching robotic sacrocolpopexy to physicians.
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Affiliation(s)
- Khushabu Kasabwala
- Department of Urology, Weill Cornell Medical College, New York Presbyterian Hospital, 525 E 68th St, F9 West, 9th floor, New York, NY, 10065, USA
| | - Ramy Goueli
- Department of Urology, Weill Cornell Medical College, New York Presbyterian Hospital, 525 E 68th St, F9 West, 9th floor, New York, NY, 10065, USA
| | - Patrick J Culligan
- Department of Urology, Weill Cornell Medical College, New York Presbyterian Hospital, 525 E 68th St, F9 West, 9th floor, New York, NY, 10065, USA.
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A National Contemporary Analysis of Perioperative Outcomes for Vaginal Vault Prolapse: Minimally Invasive Sacrocolpopexy Versus Nonmesh Vaginal Surgery. Female Pelvic Med Reconstr Surg 2019; 25:342-346. [DOI: 10.1097/spv.0000000000000678] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Linder BJ, Occhino JA, Habermann EB, Glasgow AE, Bews KA, Gershman B. A National Contemporary Analysis of Perioperative Outcomes of Open versus Minimally Invasive Sacrocolpopexy. J Urol 2018; 200:862-867. [DOI: 10.1016/j.juro.2018.03.131] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/29/2018] [Indexed: 10/17/2022]
Affiliation(s)
| | - John A. Occhino
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota
| | - Elizabeth B. Habermann
- Surgical Outcomes Program, Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
| | - Amy E. Glasgow
- Surgical Outcomes Program, Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
| | - Katherine A. Bews
- Surgical Outcomes Program, Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
| | - Boris Gershman
- Division of Urology, Rhode Island Hospital and The Miriam Hospital, Providence, Rhode Island
- Warren Alpert Medical School of Brown University, Providence, Rhode Island
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A systematic review of the learning curve in robotic surgery: range and heterogeneity. Surg Endosc 2018; 33:353-365. [DOI: 10.1007/s00464-018-6473-9] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Accepted: 09/20/2018] [Indexed: 12/18/2022]
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Anand M, Weaver AL, Fruth KM, Borah BJ, Klingele CJ, Gebhart JB. Perioperative Complications and Cost of Vaginal, Open Abdominal, and Robotic Surgery for Apical Vaginal Vault Prolapse. Female Pelvic Med Reconstr Surg 2017; 23:27-35. [PMID: 27682746 PMCID: PMC5161619 DOI: 10.1097/spv.0000000000000345] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To determine the rate of perioperative complications and cost associated with Mayo-McCall culdoplasty (MMC), open abdominal sacrocolpopexy (ASC), and robotic sacrocolpopexy (RSC) for posthysterectomy vaginal vault prolapse. METHODS We retrospectively searched for the records of patients undergoing posthysterectomy apical vaginal prolapse surgery (MMC, ASC, or RSC) between January 1, 2000, and June 30, 2012, at our institution. For all patients identified, perioperative complications, length of hospital stay, and inpatient costs to patients were abstracted from the medical records and compared by procedure. Inverse-probability-of-procedure weighting using propensity scores was used to obtain less-biased comparisons of outcomes between procedures. RESULTS A total of 512 patients met the inclusion criteria (174 MMC, 237 ASC, and 101 RSC). Using inverse-probability weighting, the MMC group had a significantly lower intraoperative complication rate (3.3% vs 11.6% for ASC, 3.4% vs 24.1% for RSC), median operative time (94 vs 217 min for ASC, 100 vs 228 min for RSC), and median cost (US $8,776 vs $12,695 for ASC, US $8,773 vs $13,107 for RSC) than the ASC and RSC groups (all P < 0.01). In addition, the MMC group had significantly fewer postoperative grade 3+ complications than the RSC group (1.1% vs 9.4%, P < 0.01). CONCLUSIONS In the treatment of posthysterectomy vaginal vault prolapse, MMC is associated with decreased non-urinary tract infection, less perioperative morbidity, and lower cost to patients compared with sacrocolpopexy.
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Affiliation(s)
- Mallika Anand
- From the *Divisions of Gynecologic Surgery, †Biomedical Statistics and Informatics, and ‡Health Care Policy and Research, Mayo Clinic, Rochester, MN
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Abstract
Background Learning curves have been described for a number of urological procedures including radical prostatectomy and laparoscopic nephrectomy but rarely for urethroplasty. We describe the learning curve for bulbar urethroplasty in a single surgeon series. Methods A retrospective case note review was performed of 91 consecutive men median age 32 years (range, 15–66 years) having bulbar urethroplasty performed by a single surgeon. Data was collected on type of urethroplasty, restricture rate (as defined by urethrogram and/or flow rate) and duration of follow up. The restricture rates were compared by quartiles and statistical analysis was by ¦Ö2 between the first and fourth quartiles. Results The 91 men had 42 dorsal onlay buccal mucosal graft (Dorsal BMG), 20 BMG augmented bulbobulbar anastomotic (Augmented Rooftop) and 29 bulbobulbar anastomotic (BBA) urethroplasties performed. Median follow up was 39 months for the first quartile, 42 months for the second, 36 months for the third, and 35 months for the fourth. The restricture rate was 17% in the first quartile, 8.7% in the second and third quartiles and 4.5% in the fourth quartile. There were no restrictures noted after 24 months. There were 4 restrictures in the first quartile and 1 restricture in the fourth quartile (¦Ö2 P<0.01). Conclusions There is a statistically and clinically significant difference in restricture rates between first and fourth quartiles with rates falling from 17% to 4.5%. There is a learning curve for bulbar urethroplasty with a reduced restricture rate each quartile and it may take as many as 90 cases to reach optimum restricture rates.
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Affiliation(s)
- Marco Spilotros
- Department of Urology, University College London Hospital, London, UK
| | - Sachin Malde
- Department of Urology, University College London Hospital, London, UK
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The impact of fellowship surgical training on operative time and patient morbidity during robotics-assisted sacrocolpopexy. Int Urogynecol J 2017; 29:1317-1323. [PMID: 28889173 DOI: 10.1007/s00192-017-3468-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Accepted: 08/21/2017] [Indexed: 10/18/2022]
Abstract
INTRODUCTION AND HYPOTHESIS Abdominal sacrocolpopexy is commonly performed for the surgical correction of pelvic organ prolapse (POP) in the USA. Over the last decade, fellowship programs have increased the number of these procedures performed robotically. Currently, there is a paucity of literature exploring the impact of fellowship training on outcomes of robotic-assisted sacrocolpopexy (RASC). We sought to explore the impact of an expert surgeon operating alone versus with a fellow on operative time and perioperative morbidity associated with RASC. METHODS This is an analysis of a retrospectively collected cohort of all RASCs performed to treat POP from June 2010 to August 2015 by a single attending surgeon. Outcomes were compared by expert surgeon alone and with a fellow. RESULTS We identified 208 RASCs, of which 124 (59.6%) were performed by an expert surgeon alone and 84 (40.4%) with a fellow. Eight fellows were included, with a median of 7 cases (interquartile range 5-13.5). Cases with fellows were 31.1 min longer than an expert surgeon alone (155.6 vs 124.5 min, p < 0.001), a 25% increase. Increased operative time for fellows remained significant on multivariate regression (34.2 min, p < 0.001) after adjusting for case order postmenopausal status, hysterectomy, mid-urethral sling, and bowel injury. Years in fellowship did not have an impact on operative time (p = 0.80). Complications were seen in 34 women (16.4%). On univariate regression, fellows did not have an impact on complications (OR 1.49, 95% CI [0.65-3.43]), which was unchanged on multivariate regression (OR 0.628, 95% CI [0.26-1.54]). Prolapse recurrence was seen in 19 women (9.5%). Fellows had no impact on prolapse recurrence (OR 0.478, 95% CI [0.17-1.38]), which was unchanged on multivariate regression (OR 0.266, 95% CI [0.17-1.49]). CONCLUSION When an expert surgeon operated together with a fellow, operative time increased by 34 min without increasing prolapse recurrence or complications.
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Nicklin J. The future of robotic-assisted laparoscopic gynaecologic surgery in Australia - A time and a place for everything. Aust N Z J Obstet Gynaecol 2017; 57:493-498. [PMID: 28857135 DOI: 10.1111/ajo.12688] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Accepted: 07/19/2017] [Indexed: 12/14/2022]
Abstract
There has been a significant increase in minimally invasive surgery in gynaecology over the last 15 years, with approximately only one-third of hysterectomies for benign disease now performed via laparotomy. While robotic surgery offers considerable technical advantages over conventional laparoscopy and is associated with only a modest learning curve, the improvement in clinical outcomes is marginal and there are several disadvantages. There are increased set-up and operating times, the need to accommodate and maintain large sophisticated equipment, and the requirement for additional training. The preeminent issue regarding the place of robotic gynaecological surgery is cost. How this is addressed and contained will ultimately determine uptake in Australia. From the published literature to date, robotic surgery compared with conventional laparoscopic surgery is associated with marginal improvements in clinical outcomes for benign hysterectomy and endometrial cancer surgery, but little improvement for other benign gynaecological surgery or for cervical cancer surgery. Robotic surgery probably does improve clinical outcomes in obese and morbidly obese patients and is associated with improved ergonomics for the surgeon. It is likely that there will be continued substantial improvements in robotic surgical platforms into the foreseeable future and that robotic surgery will play an increasingly important role in gynaecological surgery in Australia.
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Affiliation(s)
- James Nicklin
- Queensland Centre for Gynaecological Cancer, Brisbane, Queensland, Australia
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Wong M, Morris S. Conventional Laparoscopy vs. Robotic-Assisted Laparoscopy for Sacrocolpopexy and Sacrocervicopexy: a Review. CURRENT OBSTETRICS AND GYNECOLOGY REPORTS 2017. [DOI: 10.1007/s13669-017-0220-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Abstract
Sacrocolpopexy remains the "gold standard" procedure for management of posthysterectomy vaginal vault prolapse with improved anatomic outcomes compared to native tissue vaginal repair. Despite absence of clinical data, sacrocolpopexy is increasingly being offered to women as a primary treatment intervention for uterine prolapse. While reoperation rates remain low, recurrent prolapse and vaginal mesh exposure appear to increase over time. The potential morbidity associated with sacrocolpopexy is higher than for native tissue vaginal repair with complications including sacral hemorrhage, discitis, small bowel obstruction, port site herniation, and mesh erosion. Complications are more common during the learning curve of minimally invasive sacrocolpopexy. Appropriate case selection is paramount to balancing the potential for prolapse recurrence with the risk of surgical complications. Use of ultra-lightweight polypropylene mesh and vaginal mesh attachment with delayed absorbable suture may reduce the risks of vaginal mesh exposure.
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