Telementoring and telerobotics in urological surgery

Telemedicine in Overactive Bladder Syndrome

Purpose of Review

This review discusses the role and benefits of telemedicine as an integral component of the post-pandemic care paradigm in urological practice and, in particular, as part of the care of patients with overactive bladder (OAB).

Recent Findings

The COVID-19 pandemic accelerated the implementation of telemedicine across almost every medical specialty and (at least temporarily) swept away barriers including those regarding reimbursement and licensure. Telemedicine benefits patients and providers alike including savings on transportation costs, access to specialists or tertiary care from geographically remote locations, and minimized exposure to a contagious illness. Integration of telemedicine into clinical practice can reduce costs for office/exam space and staffing overhead, as well as facilitate greater scheduling efficiency. Many, if not most, aspects of care for the uncomplicated OAB patient can be as effectively managed remotely as with in-person encounters, across the treatment algorithm.

Summary

Telemedicine will almost certainly remain a key component in the care of OAB, general urology, and throughout all medical specialties.

Robotic versus laparoscopic colorectal surgery in elderly patients in terms of recovery time: a monocentric experience

Colorectal cancer has a great socio-sanitary relevance. It represents the third cancer by incidence and mortality. Ageing plays a major role in the development of colorectal cancer and this tumour, in patients aged 65 and older, has gradually increased over the past decade. The robotic technique is considered the evolution of conventional laparoscopy. Few studies evaluate the effects of robotic surgery in elderly patient, and even fewer are those that compare it with laparoscopic surgery in this population. The aim of this study was to evaluate the perioperative outcomes of robotic colorectal surgery compared to laparoscopic colorectal surgery in patients older than 65 years. We conducted a retrospective study enrolling 83 elderly patients (age > 65) undergoing robotic and laparoscopic colectomy (32 and 51, respectively) between January 2019 and January 2021. For statistical analysis, p values were calculated using t test and chi-square test. p < 0.05 is the criterion for statistical significance. Statistical analyses were performed with the Number Cruncher Statistical System (NCSS) 2020 data analysis version 20.0.1 (Utah, USA). The operation time was higher in robotic left (p = 0.003, mean time 249.6 vs 211.7 min) and right (p = 0.004, mean time 238.5 vs 183.5 min) hemicolectomy and similar for procedures on rectosigmoid and rectum when compared to laparoscopic technique. In terms of length of hospital stay and recovery of bowel function, these values were significantly lower for robotic group in left hemicolectomy (p = 0.004), rectum (p = 0.003) and rectosigmoid (p = 0.003), while right hemicolectomy was similar in two groups (p = 0.26). There was no statistically significant difference between the groups regarding conversion rate, postoperative complications, length of specimen, number of lymph nodes encountered and oncological results. Colorectal robotic surgery in elderly patients appears as a feasible and safe surgical approach when compared to the laparoscopic one, showing a shorter recovery and a reduction of length of stay with similar oncological outcomes even if with an increase of operating times.

Overcoming the Impact of COVID-19 on Surgical Mentorship: A Scoping Review of Long-distance Mentorship in Surgery

BACKGROUND

Mentorship in the surgical field has been increasingly recognized as a crucial component of career success. Distance mentorship models may be utilized to overcome geographic limitations, increase mentorship access, and strengthen mentoring relationships in surgery.

OBJECTIVE

This review aimed to identify the scope of literature on distance mentoring in surgery, the range of its application, its effectiveness, and any gaps in the literature that should be addressed in order to enhance mentorship in the surgical field.

DESIGN

A comprehensive PubMed review was performed in January 2021 on distance mentorship of students, trainees, and surgeons in the surgical field. Reviews, replies, and non-English articles were excluded. Data was extracted regarding publication year, author's country, specialty, subjects, aim of mentorship model, and efficacy.

RESULTS

134 total studies met inclusion and exclusion criteria. Most studies were published in 2020, written by authors in the United States, from general surgery, and featured an expert surgeon paired with a more junior fully trained surgeon. In all, 93.3% of studies utilized distance mentorship to enhance surgical skill through telementoring and only 4.5% were focused on mentorship to enhance careers through professional development. The remaining studies utilized distance mentorship models to increase surgical research (0.7%) and clinical knowledge (1.5%).

CONCLUSION

The results of this review suggest successful implementation of distance mentoring in surgery through telementoring, but a lack of professionally aimed distance mentorship programs. Amidst COVID-19, distance mentorship is particularly important because of decreased face-to-face opportunity. Future studies in the surgical field should investigate distance mentoring as a means of increasing mentorship for professional development.

[Medial retina clinics in 2030 : A peek into the future]

Ophthalmology is subject to constant change. Almost two decades ago the OCT (optical coherence tomography) technology was introduced into ophthalmological practice. Nowadays, artificial intelligence and telemedicine are talked about everywhere. This article gives an overview of the tools currently available in both fields. As an outlook into the year 2030, the working day of an ophthalmologist is described. All innovations discussed in this article will be available in clinical practice by then.

The Potential for Undue Patient Exposure during the Use of Telementoring Technology

Background

Surgical telementoring holds great promise for safe and effective patient care and medical education, but recording and streaming audio and video introduces the potential for exposure of patient information. Physicians maintain an ethical responsibility to protect the privacy of patients, and privacy violations may carry significant legal liability. Despite the legal treatment of violations as discrete, methods for quantifying and characterizing the exposure of patient information during procedural recordings are lacking. This study is the first to quantify the potential risk for violation of privacy when using a wearable, telementoring technology capable of video and audio recording during surgical procedures in various locations including the operating room, interventional radiology suite, and the intensive care unit.

Methods

A head-mounted recording device, Google Glass™, was used to record routine neurosurgical and critical care procedures in a convenience sample of patients. Periods of maximal risk, including the beginning of procedures, were targeted. Recordings were manually coded for discrete instances of exposure of directly identifying information and indirectly identifying information.

Results

Twenty-two procedures were recorded for a total of 12 hours, during which 807 directly identifiable exposures were found. The overall average rate of exposure was 1.13 exposures per minute. Most exposures were full-face images (90%), names (7%), or phone numbers (3%). Indirectly identifying exposures were found to be tattoos, genitals, and caretaker names. The rate of exposures was found to be lower in the operating room (OR) when compared to the intensive care unit (ICU) or interventional radiology (IR) suite (p = 0.0376).

Conclusions

High rates of potential privacy violations were discovered and found to be related the location of the procedure. Sterile draping of the face prior to recording, when appropriate, would mitigate most exposure risk, though patient names and unique tattoos may be an underappreciated source of potential exposure. This study establishes the most conservative baseline to compare techniques for preventing exposure of patient information on telementoring or video/audio recording/streaming platforms.

Lack of online video educational resources for open colorectal surgery training

BACKGROUND

Video recordings of open surgical procedures could provide a method for enhancing surgical education, analysing operative performance and presenting cases to a wider audience of surgeons. The aim of this pilot study was to systematically search the World Wide Web to determine the availability of open surgery videos and to evaluate their potential training value in terms of the educational content presented.

METHODS

A broad search for open right hemicolectomy videos was performed on the three most used English language internet search engines (Google.com, Bing.com and Yahoo.com). All videos of open right hemicolectomy with an English language title were included. Laparoscopic surgery, single-incision laparoscopic surgery and robotic- and hand-assisted surgery videos were excluded, as were videos from fee charging websites.

RESULTS

A total of 31 relevant websites were identified and 21 open surgery videos were finally included. The characteristics of the patients were presented only in four (19%) videos. A video commentary was present in 12 cases (57.1%) and this was in English language in 11. The median number of views per month was 84.1.

CONCLUSIONS

Open surgery videos have a significantly higher number of views per month compared to laparoscopic surgery videos, but current methodologies used to record and render the surgeon's point of view in open operative surgery remain limited.

Self-debriefing Model Based on an Integrated Video-Capture System: An Efficient Solution to Skill Degradation

OBJECTIVE

Video-based teaching is considered highly effective in debriefing, especially in minimally invasive surgeries. In this study, the benefits of using a new integrated video recording system, were investigated and compared to those of the standard basic skills robotic training procedure.

DESIGN

Fifty residents from the 2nd and 3rd year medical faculty without any experience of robot usage or laparoscopy were randomized into 2 groups: group A--a natural self-training group without a trainer, and group B--a self-training group assisted by an integrated video recording system during training. The training was divided into four 2-hour sessions, with a 72-hour delay between each session. Two tasks were selected for testing on the dV-Trainer, a virtual reality based robotic simulator: Match board 2 and Thread the Rings 1. After each session, the practice video recorded by the system of group B was transferred to the residents' smartphones for self-debriefing. At the end of each session, the performance score was evaluated automatically by using the simulator to plot learning curves A and B.

RESULTS

Group A showed a significant drop in performance score due to skill decay caused by the 72-hour delay. Group B exhibited a regular stepwise rising learning curve. At the end of the training, group B showed a significantly higher performance score both in Match board 2 and Thread the Rings 1. The autoanalysis and capture function, which selects only the critical errors and most valuable parts, could facilitate time saving.

CONCLUSIONS

The use of an integrated video recording system makes the self-manipulated protocol with own smartphone feasible to improve training efficiency and overcome the skill decay during robotic surgical training.

Robotic surgery for rectal cancer

Laparoscopic surgery has gained acceptance as a less invasive approach in the treatment of colon cancer. However, laparoscopic surgery for rectal cancer, particularly cancer of the lower rectum, is still challenging because of limited accessibility. Robotic surgery overcomes the limitations of laparoscopy associated with anatomy and offers certain advantages, including 3-D imaging, dexterity and ambidextrous capability, lack of tremors, motion scaling, and a short learning curve. Robotic rectal surgery has been reported to reduce conversion rates, particularly in low anterior resection, but it is associated with longer operative times than the conventional laparoscopic approach. Postoperative morbidities are similar between the robotic and conventional laparoscopic approaches, and oncological outcomes such as the quality of the mesorectum and the status of resection margins are also equivalent. The possible superiority of robotic surgery in terms of the preservation of autonomic function has yet to be established in research based on larger numbers of patients. Although robotic rectal surgery is safe, feasible, and appears to overcome some of the technical limitations associated with conventional laparoscopic surgery, the advantages provided by this technical innovation are currently limited. To justify its expensive cost, robotic surgery is more suitable for select patients, such as obese patients, men, those with cancer of the lower rectum, and those receiving preoperative chemoradiotherapy.

A novel application of teleneurology: robotic telepresence in supervision of neurology trainees

BACKGROUND

Telemedicine is used for specialist consultation, patient evaluation, and remote monitoring. We propose that telemedicine has a valuable role in medical education through facilitating faculty supervision of trainees.

MATERIALS AND METHODS

We surveyed resident physician trainees and faculty at a single institution who provided service for acute neurologic consultations over 29 months. The survey compared experiences using the supervisory methods of telephone, robotic telepresence (RTP), and in-person interaction. Participants answered 10 questions addressing their experience relevant to faculty-trainee interaction quality and clinical supervision, achieved with the three supervisory methods under study.

RESULTS

Surveys were received from 20 of 36 trainees (56%) and 8 of 10 faculty members (80%). More than 90% of trainees and faculty strongly agreed that in-person communication was satisfactory for patient data review, problem synthesis, and refinement of the trainees' impressions, with RTP ranking a close second. Moreover, 38% of faculty and 70% of trainees reported the telephone method as unsatisfactory for reacquisition of patient history, data synthesis, and direct observation of trainees' clinical skills. RTP provided more than 90% of trainees with sufficient staff support and facilitated trainee autonomy.

CONCLUSIONS

Overall, 85% of both trainees and faculty preferred in-person supervision most, with RTP ranked second and telephone being least favored. Although in-person faculty supervision of trainees' management of neurologic emergencies is always preferred, it is not always practical. This survey highlights the valuable role of RTP in graduate medical education and RTP as preferred over telephone as an adjunctive supervision tool in residency.

Safe introduction of laparoscopic colorectal surgery even in remote areas of the world: the value of a comprehensive telementoring training program

BACKGROUND

Advanced laparoscopic surgery training courses equipped with state-of-the-art lab facilities allow the acquisition of surgical skills in a harmless environment for the patients. In addition, active participation in intensive clinical mini-fellowship programs helps in acquiring clinical competence for the novice surgeons to properly manage patients affected by colorectal diseases. Despite this, inexperienced surgeons still need supervision during their first cases, especially to perform more complex laparoscopic procedures; however, availability of experts is particularly critical in remote areas of the globe. The aim of this study was to demonstrate the feasibility and effectiveness of a comprehensive theoretical and hands-on training program that included long-distance telementoring to assist inexperienced surgeons in performing laparoscopic colonic resections.

MATERIALS AND METHODS

One surgeon with no previous experience in laparoscopic colonic resection participated in an intensive training program that incorporated a theoretical master class and practical modules in the lab, including telementored sessions in experimental settings. A 4-week intensive clinical mini-fellowship was also part of the training program.

RESULTS

After completion of the extended training program, two laparoscopic colorectal resections for colon cancer were successfully performed in a remote area of Russia with telementoring assistance from Italy. A highly integrated operative room and standard secured network system were used to connect the expert and the novice surgeon. After this preliminary experience, the remote learner successfully operated on 25 more patients without any further need for remote expert assistance.

CONCLUSIONS

A comprehensive theoretical and practical mini-fellowship training program associated with initial telementoring assistance can help to safely start to perform advanced laparoscopic procedures, even in remote areas of the globe.

Novel training methods for robotic surgery

Objectives:

The objectives of this review are to summarize the current training modalities and assessment tools used in urological robotic surgery and to propose principles to guide the formation of a comprehensive robotics curriculum.

Materials and Methods:

The PUBMED database was systematically searched for relevant articles and their citations utilized to broaden our search. These articles were reviewed and summarized with a focus on novel developments.

Results:

A multitude of training modalities including didactic, dry lab, wet lab, and virtual reality have been developed. The use of these modalities can be divided into basic skills-based exercises and more advanced procedure-based exercises. Clinical training has largely followed traditional methods of surgical teaching with the exception of the unique development of tele-mentoring for the da Vinci interface. Tools to assess both real-life and simulator performance have been developed, including adaptions from Fundamentals of Laparoscopic Surgery and Objective Structured Assessment of Technical Skill, and novel tools such as Global Evaluative Assessment of Robotic Skills.

Conclusions:

The use of these different entities to create a standardized curriculum for robotic surgery remains elusive. Selection of training modalities and assessment tools should be based upon performance data-based validity and practical feasibility. Comparative assessment of different modalities (cross-modality validity) can help strengthen the development of common skill sets. Constant data collection must occur to guide continuing curriculum improvement.

Robotic-assisted versus laparoscopic colorectal surgery: a meta-analysis of four randomized controlled trials

Background

Robotic-assisted laparoscopy is popularly performed for colorectal disease. The objective of this meta-analysis was to compare the safety and efficacy of robotic-assisted colorectal surgery (RCS) and laparoscopic colorectal surgery (LCS) for colorectal disease based on randomized controlled trial studies.

Methods

Literature searches of electronic databases (Pubmed, Web of Science, and Cochrane Library) were performed to identify randomized controlled trial studies that compared the clinical or oncologic outcomes of RCS and LCS. This meta-analysis was performed using the Review Manager (RevMan) software (version 5.2) that is provided by the Cochrane Collaboration. The data used were mean differences and odds ratios for continuous and dichotomous variables, respectively. Fixed-effects or random-effects models were adopted according to heterogeneity.

Results

Four randomized controlled trial studies were identified for this meta-analysis. In total, 110 patients underwent RCS, and 116 patients underwent LCS. The results revealed that estimated blood losses (EBLs), conversion rates and times to the recovery of bowel function were significantly reduced following RCS compared with LCS. There were no significant differences in complication rates, lengths of hospital stays, proximal margins, distal margins or harvested lymph nodes between the two techniques.

Conclusions

RCS is a promising technique and is a safe and effective alternative to LCS for colorectal surgery. The advantages of RCS include reduced EBLs, lower conversion rates and shorter times to the recovery of bowel function. Further studies are required to define the financial effects of RCS and the effects of RCS on long-term oncologic outcomes.

The use of telemedicine in Italian Blood Banks: a nationwide survey

BACKGROUND

Telemedicine is defined as the use of electronic information and communication technologies to provide health care between distant people. Many activities in transfusion medicine could benefit from the application of telemedicine. To map the spread of the use of telemedicine in transfusion medicine in Italy, the Italian Society of Transfusion Medicine and Immunohaematology (SIMTI) performed a nationwide survey: the results are presented in this paper.

MATERIALS AND METHODS

A survey, dealing with different aspects of the use of telemedicine, was performed by sending a questionnaire to 280 Italian Blood Centres. The survey was designed to evaluate the diffusion of telemedicine and the features of the systems, with special attention to the systems' safety and legal adequacy. One section of the questionnaire was designed to identify the features of the systems considered essential by the respondents.

RESULTS

Out of 280 Blood Services contacted, 196 (70%) filled in at least one of the questions of the online questionnaire. Globally the use of some form of telemedicine was reported by 70% of the respondents. Telemedicine is used for remote validation of laboratory tests by 32% of the Centres that responded, for remote biological validation of blood units by 34% and for assignment of blood components by 29%. Less frequently, telemedicine is used to control electronic refrigerators, for electronic blood requests and for bed-side identification of patients.

DISCUSSION

The use of telemedicine is widespread in Italian Blood Services. There appears to be some heterogeneity between structures with regards to the evaluation of the systems' safety and their legal adequacy. No telemedicine system should be introduced into practice until it has proven to have the same standards of safety as the corresponding "on site" activity.

Introduction to haptics for neurosurgeons

Robots are becoming increasingly relevant to neurosurgeons, extending a neurosurgeon's physical capabilities, improving navigation within the surgical landscape when combined with advanced imaging, and propelling the movement toward minimally invasive surgery. Most surgical robots, however, isolate surgeons from the full range of human senses during a procedure. This forces surgeons to rely on vision alone for guidance through the surgical corridor, which limits the capabilities of the system, requires significant operator training, and increases the surgeon's workload. Incorporating haptics into these systems, ie, enabling the surgeon to "feel" forces experienced by the tool tip of the robot, could render these limitations obsolete by making the robot feel more like an extension of the surgeon's own body. Although the use of haptics in neurosurgical robots is still mostly the domain of research, neurosurgeons who keep abreast of this emerging field will be more prepared to take advantage of it as it becomes more prevalent in operating theaters. Thus, this article serves as an introduction to the field of haptics for neurosurgeons. We not only outline the current and future benefits of haptics but also introduce concepts in the fields of robotic technology and computer control. This knowledge will allow readers to be better aware of limitations in the technology that can affect performance and surgical outcomes, and "knowing the right questions to ask" will be invaluable for surgeons who have purchasing power within their departments.

Inpatient urological surgery at critical access hospitals in the United States

PURPOSE

To better understand urological care delivery in rural communities, we evaluated the utilization, outcomes and costs of inpatient urological surgery at critical access hospitals.

MATERIALS AND METHODS

Using data from the AHA (American Hospital Association) and NIS (Nationwide Inpatient Sample), we identified all urological surgical admissions to critical and noncritical access hospitals from 2005 through 2009. We compared the distribution of urological procedures, hospital mortality, length of stay and costs for patients undergoing common urological operations at critical vs noncritical access hospitals.

RESULTS

Of the 1,292 critical and 3,760 noncritical access hospitals reporting to the AHA 450 (35%) and 1,372 (36%), respectively, had at least 1 year of data available in the NIS. We identified 333,925 urological surgical admissions, including 2,286 (0.7%) to critical access hospitals. Overall, at least 1 inpatient urological operation was performed at only 45% of critical access hospitals vs 91% of noncritical access hospitals (p <0.001). The distribution of urological surgeries differed between critical and noncritical access hospitals (p <0.001) with a greater prevalence of operations for benign indications at critical access hospitals. For 6 common inpatient urological surgeries we found no meaningful difference in in-hospital mortality and prolonged length of stay between patients treated at critical vs noncritical access hospitals. However, costs at critical access hospitals were universally higher.

CONCLUSIONS

Inpatient urological surgery is performed at only a few critical access hospitals. While in-hospital mortality and length of stay are largely indistinguishable between critical and noncritical access hospitals, the higher costs at critical access hospitals may pose a challenge to improving rural access to urological care.

Robot-assisted laparoscopic surgery of the colon and rectum

INTRODUCTION

Laparoscopic techniques have induced a tremendous revolution in the field of general surgery. Recent multicenter trials have demonstrated similar patient-oriented and oncologic outcomes for laparoscopic colon and rectal resections compared with their open counterparts. Meanwhile, robotic technology has gradually entered the field of general surgery, allowing increased dexterity, improved operative view, and optimal ergonomics. The objective of this study was to review the current status of clinical robotic applications in colorectal surgery.

METHODS

A systematic review of the literature using the PubMed search engine was undertaken to identify relevant articles. The keywords used in all possible combinations were: surgical robotics, robotic surgery, computer-assisted surgery, colectomy, sigmoid resection, sigmoidectomy, and rectal resection.

RESULTS

Thirty-nine case series or comparative nonrandomized studies were identified. A specific interest for robot-assisted rectal surgery during the past few years was recorded in the literature. The retrieved articles included 13 ileocecal resections, 220 right colectomies, 190 left colectomies/sigmoid resections, 440 anterior resections, 149 abdominoperineal/intersphincteric resections, and 11 total/subtotal colectomies. The clinical application of the da Vinci robotic system in right and left/sigmoid colectomies yielded satisfactory results in terms of open conversion (1.1 and 3.8%, respectively) and operative morbidity (13.4 and 15.1%, respectively). Robot-assisted anterior resection was accompanied by a considerably low conversion rate (0.4%), morbidity (9.7%), and adequate number of harvested lymph nodes (14.3, mean).

CONCLUSIONS

Robotic applications in colorectal surgery are feasible with low conversion rates and favorable morbidity. Further studies are required to evaluate its oncologic and patient-oriented outcomes.