“Thermal spread of vessel-sealing devices evaluated in a clinically relevant in vitro model.”
Eberli, D., L. J. Hefermehl, et al. (2011).
Urologia Internationalis 86(4): 476-482.
Introduction: Bipolar vessel-sealing devices (VSDs) have advantages in urological surgeries (less hemorrhage, shorter operating time). However, these instruments can cause thermal injuries, which can result in neural damage and necrosis. The objectives of this study were to establish a reproducible in vitro model for standardized assessment of electrosurgical devices and to evaluate whether optimized placement of surgical instruments can reduce the thermal spread. Methods: We evaluated thermal spread of two VSDs in vitro using thin bovine muscle strips. Thermal injury was measured using an infrared camera, temperature probes and histology. The recordings were made with the VSD alone and with a rectangular clamp next to the VSD. Results: Both instruments showed a significant temperature spread of 2.5 mm lateral to the VSD. The placement of a metal clamp next to the VSD significantly reduced the temperature spread. Histological examinations were able to underline these findings. Conclusions: In this study we describe a straightforward clinically relevant in vitro model for the evaluation of future electrosurgical instruments. We demonstrated that the thermal spread of VSD could be further reduced by optimized placement of an additional surgical instrument. Our results could help surgeons protect sensitive structures like nerves in the vicinity of the VSD. Copyright © 2011 S. Karger AG, Basel.
“A Guide to Stereoscopic 3D Displays in Medicine.”
Held, R. T. and T. T. Hui (2011).
Academic Radiology 18(8): 1035-1048.
Stereoscopic displays can potentially improve many aspects of medicine. However, weighing the advantages and disadvantages of such displays remains difficult, and more insight is needed to evaluate whether stereoscopic displays are worth adopting. In this article, we begin with a review of monocular and binocular depth cues. We then apply this knowledge to examine how stereoscopic displays can potentially benefit diagnostic imaging, medical training, and surgery. It is apparent that the binocular depth information afforded by stereo displays 1) aid the detection of diagnostically relevant shapes, orientations, and positions of anatomical features, especially when monocular cues are absent or unreliable; 2) help novice surgeons orient themselves in the surgical landscape and perform complicated tasks; and 3) improve the three-dimensional anatomical understanding of students with low visual-spatial skills. The drawbacks of stereo displays are also discussed, including extra eyewear, potential three-dimensional misperceptions, and the hurdle of overcoming familiarity with existing techniques. Finally, we list suggested guidelines for the optimal use of stereo displays. We provide a concise guide for medical practitioners who want to assess the potential benefits of stereo displays before adopting them. © 2011 .
“Achieving realistic postoperative expectations in the prostatectomy populationis it possible?”
Krupski, T. L. (2011).
Journal of Urology 186(2): 373-374.
“Surgical case volume in Canadian urology residency: A comparison of trends in open and minimally invasive surgical experience.”
Mamut, A. E., K. Afshar, et al. (2011).
Journal of Endourology 25(6): 1063-1067.
Background and Purpose: The application of minimally invasive surgery (MIS) has become increasingly common in urology training programs and clinical practice. Our objective was to review surgical case data from all 12 Canadian residency programs to identify trends in resident exposure to MIS and open procedures. Materials and Methods: Every year, beginning in 2003, an average of 41 postgraduate year 3 to 5 residents reported surgical case data to a secure internet relational database. Data were anonymized and extracted for the period 2003 to 2009 by measuring a set of 11 predefined index cases that could be performed in both an open and MIS fashion. Results: 16,687 index cases were recorded by a total of 198 residents. As a proportion, there was a significant increase in MIS from 12% in 2003 to 2004 to 32% in 2008 to 2009 (P=0.01). A significant decrease in the proportion of index cases performed with an open approach was also observed from 88% in 2003 to 2004 to 68% in 2008 to 2009 (P=0.01). The majority of these shifts were secondary to the increased application of MIS for nephrectomies of all type (29%-45%), nephroureterectomy (27%-76%), adrenalectomy (15%-71%), and pyeloplasty (17%-54%) (P<0.0001 for all). While there was a significant increase in MIS experience with radical prostatectomy (2%-18%, P<0.0001), the majority of these were still taught in an open fashion during the study period. Conclusion: MIS constitutes an increasingly significant component of surgical volume in Canadian urology residencies with a reciprocal decrease in exposure to open surgery. These trends necessitate ongoing evaluation to maintain the integrity of postgraduate urologic training. © Copyright 2011, Mary Ann Liebert, Inc.
“Trends in the care of radical prostatectomy in the United States from 2003 to 2006.”
Williams, S. B., S. M. Prasad, et al. (2011).
BJU International 108(1): 49-55.
There is an increasing trend of minimally invasive treatments for prostate cancer with increased utilization of robotic technology contributing largely to this trend. Our study found that increased utilization of MIRP corresponded with a decreasing trend for complications, blood transfusions, lengths of stay and need for reoperation. Additionally, MIRP was found to have fewer associated complications compared with men undergoing open procedures. OBJECTIVE • To determine differences in surgical outcomes by surgical approach during a period of rapid adoption of minimally invasive surgical approaches in radical prostatectomy. PATIENTS AND METHODS • We identified 19 542 men undergoing minimally invasive (MIRP), perineal (PRP), and retropubic (RRP) radical prostatectomy from 2003 to 2006 from the MarketScan® Medstat database, a national employer-based administrative database. • We assessed for temporal trends in perioperative complications, use of postoperative cystography and anastomotic strictures by surgical approach. RESULTS • Between 2003 and 2006, MIRP use increased 33.6% vs 31.8% and 1.7% decreases in RRP and PRP, respectively. During the 4-year study, median length of stay for MIRP decreased from 2.0 to 1.0 day (P= 0.004) and overall perioperative complications decreased from 13.8 to 10.7%, (P= 0.023). • These findings were driven by reductions in genitourinary complications (3.3 to 2.5%, P= 0.049), miscellaneous surgical complications (3.6 to 2.3%, P= 0.006) and intestinal injury (1.5 to 0.1%, P= 0.009). • Median length of stay for RRP decreased from 3.2 to 2.9 days, (P < 0.001), overall perioperative complications decreased from 18.1 to 14.6%, (P= 0.007), because of reductions in both wound/bleeding complications (2.0 to 1.1%, P= 0.002) and heterologous blood transfusions. • Men undergoing MIRP vs RRP were less likely to have perioperative complications (12.5 vs 17.1%, P < 0.001), blood transfusions (1.5 vs 8.9%, P < 0.001) and anastomotic strictures (6.3 vs 12.8%, P < 0.001), and they had shorter mean lengths of stay (1.8 vs 3.1 days, P < 0.001) during the study period. CONCLUSION • The increased use of MIRP corresponds with a decreasing trend for complications, blood transfusions, lengths of stay and need for reoperation. Additionally, MIRP was found to have fewer associated complications compared with men undergoing open procedures. Further study is needed to assess the impact of tumour characteristics and surgeon volume on these perioperative outcomes as well as effects on long-term cancer control. © 2010 BJU International.
“The learning curve for laparoscopic radical prostatectomy: An international multicenter study – Commentary.”
Winfield, H. N. (2011).
Journal of Endourology 25(6): 898-899.
“Patient preoperative expectations of urinary, bowel, hormonal and sexual functioning do not match actual outcomes 1 year after radical prostatectomy.”
Wittmann, D., C. He, et al. (2011).
Journal of Urology 186(2): 494-499.
Purpose: We studied patient expectations of post-prostatectomy recovery from urinary incontinence, and urinary irritable, hormonal, bowel and sexual function symptoms after preoperative counseling. Materials and Methods: Patients undergoing radical prostatectomy, recruited between June 2007 and November 2008, were extensively counseled preoperatively regarding expected outcomes. They were assessed at baseline and 1 year after surgery using the short form of the Expanded Prostate Index Composite. Their baseline expectations of functional outcomes 1 year after surgery were assessed using the Expanded Prostate Index Composite-Expectations. Pearson’s correlation coefficient and a multiple linear regression were used to assess the associations between Expanded Prostate Index Composite-Expectations and Expanded Prostate Index Composite-Short Form at baseline and 1 year. Results: A total of 152 consenting patients completed all questionnaires. Baseline sexual function score predicted significantly expectations of sexual function (p <0.0001) and urinary incontinence (p <0.0001) scores. Expanded Prostate Index Composite-Expectations predicted Expanded Prostate Index Composite-sexual function at 1 year (p <0.0001). Of the patients 36% and 40% expected the same as baseline function at 1 year in urinary incontinence and sexual function, respectively, and 17%, 45%, 39%, 15% and 32% expected worse than baseline function at 1 year in urinary incontinence, urinary irritable symptoms, bowel function, hormonal function and sexual function, respectively. One year after prostatectomy fewer than 22% of patients attained lower than expected urinary irritable symptoms, and bowel and hormonal function. However, 47% and 44% of patients attained lower than expected function for urinary incontinence and sexual function, respectively. Surprisingly 12% and 17% of patients expected better than baseline urinary incontinence and sexual function at 1 year after surgery. Conclusions: Men have unrealistic expectations of urinary and sexual function after prostatectomy despite preoperative counseling. We hypothesize potentially responsible psychological mechanisms. These data provide a baseline for further preoperative educational interventions. © 2011 American Urological Association Education and Research, Inc.
“Selecting robotic and laparoscopic surgery in surgical oncology: Fast progress but need for evidence.”
Hottenrott, C. (2011).
Gastric and Breast Cancer 10(3): 192-199.
Although there is no evidence for improving overall survival, comparative-effectiveness research indicates better short-term outcome and quality-of-life with minimally invasive surgery than open surgery for specific cancer types. For example, laparoscopic colectomy has been the standard for colon cancer in specialized hospital. Positive results are also reported recently for laparoscopic resections of rectal and gastric cancer that may also replace open surgery in the next years. Latest advances include the use of robots as the Da Vinci Surgical System and single-incision minimally invasive techniques. Robotic surgery with prostatectomy and low anterior rectum resection is increasingly now used in the treatment of prostate and rectal cancer. Here I discuss the advances, limitations and opportunities to overcome challenges for future establishment of robotic and laparoscopic surgery for specific tumor locations personalizing surgical decisions in the treatment of solid cancers.
“Robotic surgery using the da Vinci S system-our early experiences.”
Kitano, H. (2011).
Practica Oto-Rhino-Laryngologica 104(6): 391-396.
Recently, robotic technology in the surgical field has become more widespread. However, in the field of head and neck surgery, robotic surgery has been limited because of spatial and technical limitations. The technical and optical advantages of a new robotic instrument, the da Vinci S system, enable us to perform robotic surgery in head and neck field. In this article, I discuss the advantages and disadvantages of robotic surgery using the da Vinci S system for head and neck surgery. Robotic thyroid surgery using the robotic approach has been developed mainly in Korea. In Korea, robotic thyroidectomy using a gasless, transaxillary approach is a common technique. Many papers about robotic thyroidectomy using the da Vinci S system have been published in which the technical advantages of the robotic approarch in the cosmetic results have been discussed. Another feasible approach in the head and neck region is the transoral robotic surgery (TORS) for nasopharyngeal and midline skull base tumors. This technique has been developed mainly by Weinstein and his colleagues. This new robotic surgical instrument, the da Vinci S system, is compact in comparison with the previous types. Therefore, robotic surgery via the oral cavity has become possible. Weinstein et al. mentioned in their paper that multiple institutions have shown that transoral robotic surgery programs can be successfully established yielding excellent clinical outcomes.
“Re: David R. Yates, Morgan Rouprêt, Marc-Olivier Bitker, Christophe Vaessen. to infinity and beyond: The robotic toy story. Eur Urol 2011;60:263-5.”
Patel, V. R. and A. Sivaraman (2011).
European Urology 60(2): 266-267.
“Robotic medicine in Germany: quo vadis?”
Siemer, S. and M. Stöckle (2011).
Robotische Medizin in Deutschland: quo vadis?: 1-4.
Today, one can hardly imagine the medical daily routine without computer-assisted systems, although their benefit usually is not investigated by prospective randomised trials. While in the industrial working environment computer-assisted systems are thoroughly accepted because of their precision and endurance, in medicine there are fierce debates about their use at considerably high costs. At least the perioperative advantages (e.g. less blood loss, shorter period of hospitalization), to a large extent, are beyond dispute. The high costs may be compensated by a higher volume of treated patients. Only the treatment of a higher volume of patients will lead to a reduction of infrastructure costs per case. On the other hand, only a large number of cases ensure the achievement of skills to handle such a complex system. This, in return, reduces the chance of the occurrence of complications and shorter operation times will lead to economic advantages. © 2011 Springer-Verlag.
“Emergency and weekend robotic surgery are feasible.”
Sudan, R. and S. S. Desai (2011).
Journal of Robotic Surgery: 1-4.
Robotic surgery has made a minimally invasive approach feasible for many complex operations that were previously performed by the open approach. Because of the complexity of its technology and the need for specially trained personnel, robotic operations have been limited to elective cases during weekdays. As more surgeons from different specialties perform robotic operations, the chances of scheduling conflicts and the possibility of complications needing a re-operation at night or during a weekend (defined as after hours) are also increasing. Until now, complications have been salvaged by conventional laparoscopy or laparotomy but we were able to demonstrate that, with appropriately trained staff, robotic surgery is feasible after hours and in emergencies. Use of the robot after hours could help alleviate scheduling conflicts for the operating room. For patients, it could potentially avoid laparotomy with its associated morbidity. As far as we are aware, use of the robot for emergency surgery has previously not been reported in the literature. © 2011 Springer-Verlag London Ltd.
“No longer rocket science: robots have found their place in healthcare.”
Wood (2011).
Telemedicine Journal and E-Health 17(6): 409-414.
“To infinity and beyond: The robotic toy story.”
Yates, D. R., M. Rouprêt, et al. (2011).
European Urology 60(2): 263-265.
“Robotic latissimus dorsi muscle harvest.”
Selber, J. C. (2011).
Plastic and Reconstructive Surgery 128(2): 88e-90e.
“Effectiveness of Postgraduate Training for Learning Extraperitoneal Access for Robot-Assisted Radical Prostatectomy.”
Davis, J. W., M. Achim, et al. (2011).
Journal of Endourology.
Abstract Purpose: To determine the effectiveness of postgraduate training for learning extraperitoneal robot-assisted radical prostatectomy (EP-RARP) and to identify any unmet training needs. Materials and Methods: The training resources used were live surgery observations, digital video disc instruction, postgraduate courses, and literature review. Modifications to the transperitoneal (TP) setup in equipment, patient positioning, port placement, and access technique were identified. A surgeon who had previous experience with 898 TP robot-assisted radical prostatectomies (TP-RARPs) performed EP-RARP in 30 patients. We evaluated setup results, emphasizing access-related difficulties, and compared the EP cohort with a nonrandomized, concurrent TP cohort of 62 patients for short-term outcomes. Results: The median setup time for EP was 26 minutes (range 15-65 min) for EP compared with 14 to 17 minutes for the comparable TP setup and dropping the bladder. During EP setup and dissection, peritoneal entry occurred in 37%, incorrect port spacing in 10%, epigastric vessel injury in 10%, and other minor pitfalls in 10%. No significant differences were found between EP and TP in postsetup operative times, hospital stay, complications, surgical margin status with organ-confined disease, or lymph node dissection yield. EP had significantly higher estimated blood loss (300 vs 200 mL, P=0.001) and more symptomatic lymphoceles when extended pelvic lymph node dissection was performed (3/16 vs 0/47, P=0.001). Conclusions: Using postgraduate education resources, an experienced TP-RARP surgeon successfully transitioned to EP-RARP, achieving the major objectives of safety and equivalent outcomes. We identified several minor nuances in the setup that need further refinement in future education models.
“Gynecologic Oncology Training Systems in Europe: A Report From the European Network of Young Gynaecological Oncologists.”
Gultekin, M., P. Dursun, et al. (2011).
International Journal of Gynecological Cancer.
OBJECTIVE:: The objectives of the study were to highlight some of the differences in training systems and opportunities for training in gynecologic oncology across Europe and to draw attention to steps that can be taken to improve training prospects and experiences of European trainees in gynecologic oncology. METHODS:: The European Network of Young Gynaecological Oncologists national representatives from 34 countries were asked to review and summarize the training system in their countries of origin and fulfill a mini-questionnaire evaluating different aspects of training. We report analysis of outcomes of the mini-questionnaire and subsequent discussion at the European Network of Young Gynaecological Oncologists national representatives Asian Pacific Organization for Cancer Prevention meeting in Istanbul (April 2010). RESULTS:: Training fellowships in gynecologic oncology are offered by 18 countries (53%). The median duration of training is 2.5 years (interquartile range, 2.0-3.0 years). Chemotherapy administration is part of training in 70.5% (24/34) countries. Most of the countries (26/34) do not have a dedicated national gynecologic-oncology journal. All trainees reported some or good access to training in advanced laparoscopic surgical techniques, whereas 41% indicated no access, and 59% some access to training opportunities in robotic surgery. European countries were grouped into 3 different categories on the basis of available training opportunities in gynecologic oncology: well-structured, moderately structured, and loosely structured training systems. CONCLUSIONS:: There is a need for further harmonization and standardization of training programs and structures in gynecologic oncology across Europe. This is of particular relevance for loosely structured countries that lag behind the moderately structured and well-structured ones.
“Face, Content and Construct Validity of a Novel Robotic Surgery Simulator.”
Hung, A. J., P. Zehnder, et al. (2011).
Journal of Urology.
PURPOSE: We evaluated the face, content and construct validity of the novel da Vinci(R) Skills Simulator using the da Vinci Si Surgeon Console as the surgeon interface. MATERIALS AND METHODS: We evaluated a novel robotic surgical simulator for robotic surgery using the da Vinci Si Surgeon Console and Mimic virtual reality. Subjects were categorized as novice-no surgical training, intermediate-surgical training with fewer than 100 robotic cases or expert-100 or more primary surgeon robotic cases. Each participant completed 10 virtual reality exercises with 3 repetitions and a questionnaire with a 1 to 10 visual analog scale to assess simulator realism (face validity) and training usefulness (content validity). The simulator recorded performance based on specific metrics. The performance of experts, intermediates and novices was compared (construct validity) using the Kruskal-Wallis test. RESULTS: We studied 16 novices, 32 intermediates with a median surgical experience of 6 years (range 1 to 37) and a median of 0 robotic cases (range 0 to 50), and 15 experts with a median of 315 robotic cases (range 100 to 800). Participants rated the virtual reality and console experience as very realistic (median visual analog scale score 8/10) while expert surgeons rated the simulator as a very useful training tool for residents (10/10) and fellows (9/10). Experts outperformed intermediates and novices in almost all metrics (median overall score 88.3% vs 75.6% and 62.1%, respectively, between group p <0.001). CONCLUSIONS: We confirmed the face, content and construct validity of a novel robotic skill simulator that uses the da Vinci Si Surgeon Console. Although it is currently limited to basic skill training, this device is likely to influence robotic surgical training across specialties.
“Medicolegal review of liability risks for gynecologists stemming from lack of training in robot-assisted surgery.”
Lee, Y. L., G. S. Kilic, et al. (2011).
Journal of Minimally Invasive Gynecology 18(4): 512-515.
The advances in robot-assisted surgery in gynecology evolved after most practicing gynecologists had already completed residency training. Postgraduate training in new technology for gynecologists in practice is limited. Therefore, gynecologists with insufficient training who perform robot-assisted surgery may potentially be at risk for liability. In addition to the traditional medical negligence claims, plaintiff attorneys are seeking causes of actions for lack of informed consent and negligent credentialing. Thus, it is essential that gynecologists be aware of these potential liability claims that arise in a robot-assisted malpractice suit. This commentary provides an overview of the current medicolegal liability risks originating from lack of training in robotic surgery and seeks to raise awareness of the implications involved in these claims. A better understanding of the doctrine of informed consent and seeking assistance of proctors or experienced co-surgeons early in robotics training are likely to reduce the liability risks for gynecologic surgeons.
“Learning experience using the double-console da Vinci surgical system in gynecology: a prospective cohort study in a University hospital.”
Marengo, F., D. Larrain, et al. (2011).
Archives of Gynecology and Obstetrics.
PURPOSE: To report our preliminary experience with robotic-assisted laparoscopy in a variety of gynecological surgeries in a teaching hospital. METHOD: A total of 33 patients who underwent robotic-assisted laparoscopic procedures for gynecological diseases were included in the study. All surgeries were performed using the double-console da Vinci surgical system. Patient’s demographics, surgical procedures, operative time, perioperative complications, conversion rate, hospital stay and estimated blood loss were prospectively collected. RESULTS: All procedures were completed robotically except three (9%): two cases were converted to laparotomy and one case was converted to vaginal surgery. The mean age was 47 +/- 11 and mean BMI was 23 kg/m(2). Mean time taken for docking the robot was 22 min. Mean operative time was 152 min. Mean anesthesia time was 196 min. Mean hemoglobin drop was 2 g/dL. Four complications occurred: one transitory ischemic attack, one port-site hernia managed through trocar incision, one periumbilical hematoma managed conservatively and one vaginal cuff hematoma who required laparoscopy. The mean hospital stay was 4 days. CONCLUSION: With the use of robotic technology, surgeons are able to offer minimally invasive surgery to a larger percentage of patients. Double console system seems a promising tool in surgical education, improving both resident training and participation in surgeries. A shorter adaption to robotics could be expected in teams with previous experience with standard laparoscopy, however, a stepwise start with simpler cases is the key to achieve a safe adaption to robotic surgery.
“Content validation of a novel robotic surgical simulator.”
Rao, A. R. (2011).
BJU International 108(3): E153.