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Wu SC, Swanton AR, Jones JM, Gross MS. New findings regarding the influence of assistants on surgical outcomes in penile prosthesis implantation. Int J Impot Res 2023; 35:736-740. [PMID: 36209303 DOI: 10.1038/s41443-022-00624-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 09/20/2022] [Accepted: 09/22/2022] [Indexed: 11/08/2022]
Abstract
Penile prosthesis implantation is the definitive treatment for refractory erectile dysfunction, yet exposure to this procedure during training of urology residents is often limited. To assess the effects of resident participation in penile prosthesis surgery, we compared surgical outcomes in a retrospective case series of 253 penile prosthesis surgeries by a single surgeon at the same institution between 2017 and 2020 with the assistance of either a registered nurse first assistant (RNFA) or a resident. Pertinent patient characteristics and surgical complications including device complications, surgical site infection, postoperative bleeding, iatrogenic injury, cardiovascular events, pulmonary events, and urinary retention were documented. Measured outcomes included operative time, Emergency Room (ER) visits, unplanned postoperative visits, pain medication refills, and surgical complications. Compared to RFNAs, resident-assisted penile prosthesis surgery was associated with significant increase in mean operative time (71.4 min vs. 87.9 min, p < 0.01) and postoperative ER visits (3.0% vs. 10.6%, p = 0.03) but not surgical complications (19.7% vs. 20.8%, OR 1.03, 95% CI [0.46 -2.30]) or other measured outcomes. Compared to a dedicated RFNA, Resident assistance increased operative time by approximately 17 min, but did not increase post-operative surgical complications, supporting the notion that resident assistance in these procedures may be appropriate as an integral part of training.
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Affiliation(s)
- Shuo-Chieh Wu
- Section of Urology, Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Amanda R Swanton
- Section of Urology, Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - James M Jones
- Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| | - Martin S Gross
- Section of Urology, Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA.
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Bravi CA, Dell'Oglio P, Piazza P, Scarcella S, Bianchi L, Falagario U, Turri F, Andras I, Di Maida F, De Groote R, Piramide F, Moschovas MC, Suardi N, Terrone C, Carrieri G, Patel V, Autorino R, Porpiglia F, Vickers A, Briganti A, Montorsi F, Mottrie A, Larcher A. Positive Surgical Margins After Anterior Robot-assisted Radical Prostatectomy: Assessing the Learning Curve in a Multi-institutional Collaboration. Eur Urol Oncol 2023:S2588-9311(23)00251-1. [PMID: 38036328 DOI: 10.1016/j.euo.2023.11.006] [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: 08/19/2023] [Revised: 10/08/2023] [Accepted: 11/07/2023] [Indexed: 12/02/2023]
Abstract
BACKGROUND The learning curve for robot-assisted radical prostatectomy (RARP) remains controversial, with prior studies showing that, in contrast with evidence on open and laparoscopic radical prostatectomy, biochemical recurrence rates of experienced versus inexperienced surgeons did not differ. OBJECTIVE To characterize the learning curve for positive surgical margins (PSMs) after RARP. DESIGN, SETTING, AND PARTICIPANTS We analyzed the data of 13 090 patients with prostate cancer undergoing RARP by one of 74 surgeons from ten institutions in Europe and North America between 2003 and 2022. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Multivariable models were used to assess the association between surgeon experience at the time of each patient's operation and PSMs after surgery, with adjustment for preoperative prostate-specific antigen level, grade, stage, and year of surgery. Surgeon experience was coded as the number of robotic radical prostatectomies done by the surgeon before the index patient's operation. RESULTS AND LIMITATIONS Overall, 2838 (22%) men had PSMs on final pathology. After adjusting for case mix, we found a significant, nonlinear association between surgical experience and probability of PSMs after surgery, with a lower risk of PSMs for greater surgeon experience (p < 0.0001). The probabilities of PSMs for a patient treated by a surgeon with ten, 250, 500, and 2000 prior robotic procedures were 26%, 21%, 18%, and 14%, respectively (absolute risk difference between ten and 2000 procedures: 11%; 95% confidence interval: 9%, 14%). Similar results were found after stratifying patients according to extracapsular extension at final pathology. Results were also unaltered after excluding surgeons who had moved between institutions. CONCLUSIONS While we characterized the learning curve for PSMs after RARP, the relative contribution of surgical learning to the achievement of optimal outcomes remains controversial. Future investigations should focus on what experienced surgeons do to avoid positive margins and should explore the relationship between learning, margin rate, and biochemical recurrence. Understanding what margins affect recurrence and whether these margins are trainable or a result of other factors may shed light on where to focus future efforts in surgical education. PATIENT SUMMARY In patients receiving robotic radical prostatectomy for prostate cancer, we characterized the learning curve for positive margins. The risk of surgical margins decreased progressively with increasing experience, and plateaued around the 500th procedure. Understanding what margins affect recurrence and whether these margins are trainable or a result of other factors has implications for surgeons and patients, and it may shed light on where to focus future efforts in surgical education.
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Affiliation(s)
- Carlo A Bravi
- Department of Urology, The Royal Marsden NHS Foundation Trust, London, UK; Department of Urology, Onze-Lieve-Vrouwziekenhuis Hospital, Aalst, Belgium; ORSI Academy, Ghent, Belgium.
| | - Paolo Dell'Oglio
- Department of Urology, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy; Department of Urology, Antoni van Leeuwenhoek Hospital, The Netherlands Cancer Institute, Amsterdam, The Netherlands; Interventional Molecular Imaging Laboratory, Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Pietro Piazza
- Division of Urology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Simone Scarcella
- Division of Urology, United Hospital of Ancona, School of Medicine Marche Polytechnic University, Ancona, Marche, Italy; Department of Urology, Azienda Ospedaliera Ospedali Riuniti Marche Nord, Pesaro, Italy
| | - Lorenzo Bianchi
- Division of Urology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Ugo Falagario
- Urology and Renal Transplantation Unit, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Filippo Turri
- Department of Urology, ASST Santi Paolo e Carlo, University of Milan, Milan, Italy
| | - Iulia Andras
- Department of Urology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | | | - Ruben De Groote
- Department of Urology, Onze-Lieve-Vrouwziekenhuis Hospital, Aalst, Belgium; ORSI Academy, Ghent, Belgium
| | - Federico Piramide
- School of Medicine, Division of Urology, Department of Oncology, San Luigi Gonzaga Hospital, University of Turin, Orbassano, Turin, Italy
| | | | - Nazareno Suardi
- IRCCS Ospedale Policlinico San Martino, Genova, Italy; Department of Urology, Ospedali Civili of Brescia, Brescia, Italy
| | - Carlo Terrone
- IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Giuseppe Carrieri
- Urology and Renal Transplantation Unit, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Vipul Patel
- AdventHealth Global Robotics Institute, Celebration, FL, USA
| | | | - Francesco Porpiglia
- School of Medicine, Division of Urology, Department of Oncology, San Luigi Gonzaga Hospital, University of Turin, Orbassano, Turin, Italy
| | - Andrew Vickers
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Alberto Briganti
- Division of Oncology/Unit of Urology, URI, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Francesco Montorsi
- Division of Oncology/Unit of Urology, URI, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Alexandre Mottrie
- Department of Urology, Onze-Lieve-Vrouwziekenhuis Hospital, Aalst, Belgium; ORSI Academy, Ghent, Belgium
| | - Alessandro Larcher
- Division of Oncology/Unit of Urology, URI, IRCCS Ospedale San Raffaele, Milan, Italy
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Bandin A, Staff I, McLaughlin T, Tortora J, Pinto K, Negron R, Olivo Valentin L, Dinlenc C, Wagner J. Outcomes over 20 years performing robot-assisted laparoscopic prostatectomy: a single-surgeon experience. World J Urol 2023; 41:1047-1053. [PMID: 36930256 DOI: 10.1007/s00345-023-04346-7] [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: 09/28/2022] [Accepted: 02/24/2023] [Indexed: 03/18/2023] Open
Abstract
OBJECTIVE To evaluate a single surgeon's 20-year experience with robotic radical prostatectomy. METHODS Patients who had undergone robot-assisted laparoscopic prostatectomy by a single surgeon were identified via an IRB approved prospectively maintained prostate cancer database. Patients were divided into 5-year cohorts (cohort A 2001-2005; cohort B 2006-2010; cohort C 2011-2015; cohort D 2016-2021) for analysis. Oncologic and quality of life outcomes were recorded at the time of follow-up visits. Continence was defined as 0-1 pad with occasional dribbling. Potency was defined as intercourse or an erection sufficient for intercourse within the last 4 weeks. RESULTS Three thousand one hundred fifty-two patients met criteria for inclusion. Clavien ≥ 3 complication rates decreased from 5.9% to 3.2%, p = 0.021. There was considerable Gleason grade group (GG) and stage migration to more advanced disease between cohort A (6.4% GG4 or GG5, 16.2% pT3 or pT4, 1.2% N1) and cohort D (17% GG4 or GG5, 45.5% pT3 or pT4, 14.4% N1; p < 0.001). Consistent with this, an increasing proportion of patients required salvage treatments over time (14.6% of cohort A vs 22.5% of cohort D, p < 0.001). 1-year continence rates improved from 74.8% to greater than 92.4%, p < 0.001. While baseline potency and use of intraoperative nerve spare decreased, for patients potent at baseline, there were no significant differences for potency at one year (p = 0.065). CONCLUSIONS In this 20-year review of our experience with robotic prostatectomy, complication rates and continence outcomes improved over time, and there was a migration to more advanced disease at the time of surgery.
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Affiliation(s)
- Alexander Bandin
- Urology Division, Hartford Healthcare Medical Group, Hartford Hospital, Hartford, CT, 06106, USA.
| | - Ilene Staff
- Hartford Hospital Research Program, Hartford Hospital, Hartford, CT, 06106, USA
| | - Tara McLaughlin
- Urology Division, Hartford Healthcare Medical Group, Hartford Hospital, Hartford, CT, 06106, USA
| | - Joseph Tortora
- Hartford Hospital Research Program, Hartford Hospital, Hartford, CT, 06106, USA
| | - Kevin Pinto
- Urology Division, Hartford Healthcare Medical Group, Hartford Hospital, Hartford, CT, 06106, USA
| | - Rosa Negron
- Hartford Hospital Research Program, Hartford Hospital, Hartford, CT, 06106, USA
| | - Laura Olivo Valentin
- Urology Division, Hartford Healthcare Medical Group, Hartford Hospital, Hartford, CT, 06106, USA
| | - Caner Dinlenc
- Department of Urology, Mount Sinai Beth Israel Medical Center, New York, NY, 10003, USA
| | - Joseph Wagner
- Urology Division, Hartford Healthcare Medical Group, Hartford Hospital, Hartford, CT, 06106, USA
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Masghati S, McDaniel A, Swainston D, Howard DL. Residents' Participation in Robotic Surgery and Operative Time: Does Attending Surgeons’ Volume Influence This Relationship? J Gynecol Surg 2021. [DOI: 10.1089/gyn.2020.0152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Salome Masghati
- Fellowship Program in Minimally Invasive Gynecologic Surgery, Las Vegas Minimally Invasive Surgery/University of Nevada, Las Vegas, Nevada, USA
| | - Alexandra McDaniel
- Sunrise Health GME Consortium Residency Program in Obstetrics and Gynecology, Las Vegas, Nevada, USA
| | - Darin Swainston
- Sunrise Health GME Consortium Residency Program in Obstetrics and Gynecology, Las Vegas, Nevada, USA
| | - David L. Howard
- Sunrise Health GME Consortium Residency Program in Obstetrics and Gynecology, Las Vegas, Nevada, USA
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Abstract
PURPOSE OF REVIEW This review aims to summarize innovations in urologic surgical training in the past 5 years. RECENT FINDINGS Many assessment tools have been developed to objectively evaluate surgical skills and provide structured feedback to urologic trainees. A variety of simulation modalities (i.e., virtual/augmented reality, dry-lab, animal, and cadaver) have been utilized to facilitate the acquisition of surgical skills outside the high-stakes operating room environment. Three-dimensional printing has been used to create high-fidelity, immersive dry-lab models at a reasonable cost. Non-technical skills such as teamwork and decision-making have gained more attention. Structured surgical video review has been shown to improve surgical skills not only for trainees but also for qualified surgeons. Research and development in urologic surgical training has been active in the past 5 years. Despite these advances, there is still an unfulfilled need for a standardized surgical training program covering both technical and non-technical skills.
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Devlin CM, Fowler S, Biyani CS, Forster JA. Changes in UK renal oncological surgical practice from 2008 to 2017: implications for cancer service provision and surgical training. BJU Int 2021; 128:206-217. [PMID: 33249738 DOI: 10.1111/bju.15310] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To determine and analyse the temporal changes in oncological nephrectomy practice and training opportunities using data obtained from the UK British Association of Urological Surgeons nephrectomy register from 2008 to 2017. PATIENT AND METHODS All nephrectomies within the dataset for this time period were analysed (n = 54 251). Cases were divided into radical nephrectomy (RN), partial nephrectomy (PN) and nephroureterectomy (NU). Simple nephrectomy, donor nephrectomy and benign PN were excluded. The annual frequencies for each oncological nephrectomy method, surgical approach, grade of surgeon, hospital caseload numbers and short-term surgical outcomes were determined. RESULTS Reported annual nephrectomy numbers increased by 2.5-fold in the 9-year time period. The number of hospitals performing nephrectomies decreased by 22%, however, more than 40% of centres performed more than 70 cases a year. There was a trend towards a decrease in overall length of hospital stay (9 vs 5 days; P < 0.01) and decreased transfusion rates. The proportion of minimally invasive procedures increased from 57% to 75%, with nephron-sparing rates increasing from 8.9% overall to 24.8%. With regard to surgical technique, robot-assisted surgery saw a mean annual increase of 222%. Overall, there was a 10% decrease in the proportion of PNs performed by trainee surgeons. CONCLUSIONS Renal surgery has changed considerably with regard to volume and also surgical approach, with rates of nephron-sparing surgery and minimally invasive surgery significantly increasing. Increasing hospital centralization and institutional experience, and a shift to robot-assisted surgery appear to have contributed to the observed improved patient outcomes. The increasing utilization of robot-assisted surgery has potential implications and challenges for the training of future urology surgeons.
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Affiliation(s)
- Conor M Devlin
- Urology Department, Bradford Royal Infirmary, Bradford Teaching Hospitals Foundation Trust, Bradford, UK
| | - Sarah Fowler
- British Association of Urological Surgeons, London, UK
| | - Chandra Shekhar Biyani
- Department of Urology, St James's University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - James A Forster
- Urology Department, Bradford Royal Infirmary, Bradford Teaching Hospitals Foundation Trust, Bradford, UK
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Yip W, Vij SC, Li J, Samplaski MK. The effect of trainee involvement on surgical outcomes and complications of male infertility surgical procedures. Andrologia 2020; 52:e13719. [PMID: 32557781 DOI: 10.1111/and.13719] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Accepted: 05/28/2020] [Indexed: 11/27/2022] Open
Abstract
In this study, we sought to determine the effect of trainee (resident or fellow physician) involvement in male infertility surgical procedures on patient surgical outcomes and complications. The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database was retrospectively reviewed for fertility surgical procedures from 2006 to 2012. The procedures included were as follows: epididymectomy, spermatocelectomy, varicocelectomy ± hernia repair, ejaculatory duct resection, vasovasostomy, vasoepididymostomy and 'unlisted procedure male genital system' (to capture sperm retrieval procedures). A variety of peri- and post-operative outcomes were examined. Trainee and nontrainee-involved groups were compared by Wilcoxon rank sum tests, followed by logistic regression, univariate and multivariate analyses. 924 cases were included: 309 with trainees and 615 without. The median post-graduate trainee year was 3 (range: 0-10). Patients in the trainee-involved cohort had higher rates of chronic obstructive pulmonary disease, steroid usage and black race. Mean operative time was 42.5% longer in trainee-involved cases, even after controlling for other covariates (76.2 vs. 49.5 min, p = .00). Hospital stay length was also longer in trainee-involved cases (0.41 vs. 0.35 days, p = .02). There were no differences in superficial infections (p = 1.00), deep wound infections (p = 1.00), urinary tract infections (p = .26), or reoperations (p = .23) with or without trainee involvement.
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Affiliation(s)
- Wesley Yip
- Institute of Urology, University of Southern California, Los Angeles, CA, USA
| | - Sarah C Vij
- Glickman Urological and Kidney Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Jianbo Li
- Glickman Urological and Kidney Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Mary K Samplaski
- Institute of Urology, University of Southern California, Los Angeles, CA, USA
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Benton JZ, Lodh A, Wallis CJD, Klaassen Z. EDITORIAL COMMENT. Urology 2019; 132:47-48. [PMID: 31581997 DOI: 10.1016/j.urology.2019.05.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Accepted: 05/16/2019] [Indexed: 10/25/2022]
Affiliation(s)
| | - Atul Lodh
- Medical College of Georgia, Augusta, GA
| | | | - Zachary Klaassen
- Division of Urology, Medical College of Georgia - Augusta University, Augusta, GA; Georgia Cancer Center, Augusta, GA
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