Multidisciplinary integrated care pathway for von Hippel-Lindau disease.

BACKGROUND: Clinical pathways are care plans established to describe essential steps in the care of patients with a specific clinical problem. They translate (inter)national guidelines into local applicable protocols and clinical practice. The purpose of this article is to establish a multidisciplinary integrated care pathway for specialists and allied health care professionals in caring for individuals with von Hippel-Lindau (VHL) disease. METHODS: Using a modified Delphi consensus-making process, a multidisciplinary panel from 5 Dutch University Medical Centers produced an integrated care pathway relating to the provision of care for patients with VHL by medical specialists, specialized nurses, and associated health care professionals. Patient representatives cocreated the pathway and contributed quality criteria from the patients' perspective. RESULTS: The panel agreed on recommendations for the optimal quality of care for individuals with a VHL gene mutation. These items were the starting point for the development of a patient care pathway. With international medical guidelines addressing the different VHL-related disorders, this article presents a patient care pathway as a flowchart that can be incorporated into VHL expertise clinics or nonacademic treatment clinics. CONCLUSIONS: Medical specialists (internists, urologists, neurosurgeons, ophthalmologists, geneticists, medical oncologists, neurologists, gastroenterologists, pediatricians, and ear-nose-throat specialists) together with specialized nurses play a vital role alongside health care professionals in providing care to people affected by VHL and their families. This article presents a set of consensus recommendations, supported by organ-specific guidelines, for the roles of these practitioners in order to provide optimal VHL care. This care pathway can form the basis for the development of comprehensive, integrated pathways for multiple neoplasia syndromes.

Estimating Surgical Urethral Length on Intraoperative Robot-Assisted Prostatectomy Images Using Artificial Intelligence Anatomy Recognition.

Objective: To construct a convolutional neural network (CNN) model that can recognize and delineate anatomic structures on intraoperative video frames of robot-assisted radical prostatectomy (RARP) and to use these annotations to predict the surgical urethral length (SUL). Background: Urethral dissection during RARP impacts patient urinary incontinence (UI) outcomes, and requires extensive training. Large differences exist between incontinence outcomes of different urologists and hospitals. Also, surgeon experience and education are critical toward optimal outcomes. Therefore, new approaches are warranted. SUL is associated with UI. Artificial intelligence (AI) surgical image segmentation using a CNN could automate SUL estimation and contribute toward future AI-assisted RARP and surgeon guidance. Methods: Eighty-eight intraoperative RARP videos between June 2009 and September 2014 were collected from a single center. Two hundred sixty-four frames were annotated according to prostate, urethra, ligated plexus, and catheter. Thirty annotated images from different RARP videos were used as a test data set. The dice (similarity) coefficient (DSC) and 95th percentile Hausdorff distance (Hd95) were used to determine model performance. SUL was calculated using the catheter as a reference. Results: The DSC of the best performing model were 0.735 and 0.755 for the catheter and urethra classes, respectively, with a Hd95 of 29.27 and 72.62, respectively. The model performed moderately on the ligated plexus and prostate. The predicted SUL showed a mean difference of 0.64 to 1.86 mm difference vs human annotators, but with significant deviation (standard deviation = 3.28-3.56). Conclusion: This study shows that an AI image segmentation model can predict vital structures during RARP urethral dissection with moderate to fair accuracy. SUL estimation derived from it showed large deviations and outliers when compared with human annotators, but with a small mean difference (<2 mm). This is a promising development for further research on AI-assisted RARP.

Assessment of basic laparoscopic skills on virtual reality simulator or box trainer.

INTRODUCTION: We investigated whether the peg transfer task is interchangeable between a VR simulator and a box trainer. Our research questions: (1) Are scores of the box trainer interchangeable with the virtual equivalent of the exercise; (2) does training on the box affect performance on the VR simulator and vice versa; and (3) which system is preferred? METHODS: Experienced laparoscopists and medical interns were randomly assigned to one of two groups (V or B). They performed eight repetitions of the peg transfer task (4 on each simulator system) following a crossover study design. Group B started on the box trainer and group V started on the VR simulator. Opinion of participants was evaluated by a questionnaire. RESULTS: A significant correlation was found between time to complete the task on the box and the VR simulator. The comparison of the performances per system showed that group B (N = 14) performed the peg transfer task on the VR simulator in significantly less time than group V (N = 14; p = 0.014). Overall, the box was preferred over the VR simulator. CONCLUSIONS: Although performances on the box trainer and VR simulator were correlated, they were not interchangeable. The results also imply that assessment on the VR simulator after pretraining on the box is acceptable, whereas VR simulator training alone might not suffice to pass an assessment on a box trainer. More research is needed to validate the use of the VR simulator as a FLS and PLUS assessment instrument.

Single versus multimodality training basic laparoscopic skills.

INTRODUCTION: Even though literature provides compelling evidence of the value of simulators for training of basic laparoscopic skills, the best way to incorporate them into a surgical curriculum is unclear. This study compares the training outcome of single modality training with multimodality training of basic laparoscopic skills. METHODS: Thirty-six medical students without laparoscopic experience performed six training sessions of 45 min each, one per day, in which four different basic tasks were trained. Participants in the single-modality group (S) (n = 18) practiced solely on a virtual reality (VR) simulator. Participants in the multimodality group (M) (n = 18) practiced on the same VR simulator (2x), a box trainer (2x), and an augmented reality simulator (2x). All participants performed a pre-test and post-test on the VR simulator (the four basic tasks + one additional basic task). Halfway through the training protocol, both groups performed a salpingectomy on the VR simulator as interim test. RESULTS: Both groups improved their performance significantly (Wilcoxon signed-rank, P < 0.05). The performances of group S and group M in the additional basic task and the salpingectomy did not differ significantly (Mann-Whitney U test, P > 0.05). Group S performed the four basic tasks in the post-test on the VR faster than group M (P ≤ 0.05), which can be explained by the fact that they were much more familiar with these tasks. CONCLUSIONS: Training of basic laparoscopic tasks on single or multiple modalities does not result in different training outcome. Both training methods seem appropriate for the attainment of basic laparoscopic skills in future curricula.

Criterion-based laparoscopic training reduces total training time.

INTRODUCTION: The benefits of criterion-based laparoscopic training over time-oriented training are unclear. The purpose of this study is to compare these types of training based on training outcome and time efficiency. METHODS: During four training sessions within 1 week (one session per day) 34 medical interns (no laparoscopic experience) practiced on two basic tasks on the Simbionix LAP Mentor virtual-reality (VR) simulator: 'clipping and grasping' and 'cutting'. Group C (criterion-based) (N = 17) trained to reach predefined criteria and stopped training in each session when these criteria were met, with a maximum training time of 1 h. Group T (time-based) (N = 17) trained for a fixed time of 1 h each session. Retention of skills was assessed 1 week after training. In addition, transferability of skills was established using the Haptica ProMIS augmented-reality simulator. RESULTS: Both groups improved their performance significantly over the course of the training sessions (Wilcoxon signed ranks, P < 0.05). Both groups showed skill transferability and skill retention. When comparing the performance parameters of group C and group T, their performances in the first, the last and the retention training sessions did not differ significantly (Mann-Whitney U test, P > 0.05). The average number of repetitions needed to meet the criteria also did not differ between the groups. Overall, group C spent less time training on the simulator than did group T (74:48 and 120:10 min, respectively; P < 0.001). Group C performed significantly fewer repetitions of each task, overall and in session 2, 3 and 4. CONCLUSIONS: Criterion-based training of basic laparoscopic skills can reduce the overall training time with no impact on training outcome, transferability or retention of skills. Criterion-based should be the training of choice in laparoscopic skills curricula.

Improving Robotic Skills by Video Review.

Background: Since the transition of surgical robot systems into the medical field, physicians have had to develop new dexterity skills. The ideal learning environment for robotic surgery has yet to be discovered. Virtual reality (VR) simulation is a possible safe and economic method. In VR simulator training human feedback is hardly used, and an alternative may be found in video revision. The purpose of this study is to investigate whether adding video review to VR simulation-based training in novice physicians improves their ability to complete a complex robot task. In addition, the secondary goal is to investigate whether the skills learned on the robotic simulator can be transferred to a real robotic system. Materials and Methods: Forty participants, medical students and, medical-PhD candidates, from one university hospital were included. Baseline dexterity skills were measured through completion of a vesicourethral anastomosis on a VR robot simulator and the da Vinci robot. Participants were randomized into a video and control group. The video group practiced skills on the robot simulator with intermediate video revision, whereas the control group had intermediate pause instead. Postintervention dexterity skills were measured using the same exercises as the baseline tests. Results: No significant differences were found in baseline performance. Postintervention results on the VR simulator show that the video group commits significantly fewer injuries to the urethra and sutures at a greater optimal depth. The control group was significantly faster, had less camera travel, and had their instruments less out of view. On the da Vinci robot, participants in both groups performed significantly faster and had better global evaluative assessment of robotic skill score after the training sessions on the VR simulator. Conclusions: Video revision significantly improves the quality of robotic skills in novice surgeons on the VR simulator, although at the expense of time. Furthermore, both groups demonstrated enhanced skills on the da Vinci robot after training sessions, which advocates transferability of skill.

Identifying the relationship between postoperative urinary continence and residual urethra stump measurements in robot assisted radical prostatectomy patients.

OBJECTIVE: To investigate the feasibility of urethral stump length and width measurements in recorded videos of robot assisted radical prostatectomy procedures using the Kinovea software and to assess if these measurements could be used as predictors of postoperative urinary continence. METHODS: Fifty-three patients were selected from an institutional database of 1400 cases and included in the study. All videos were analysed using the computer software 'Kinovea'. All measurements were performed using the inserted bladder catheter as a reference point. RESULTS: The reference point (bladder catheter) was available in 33 out of 53 patients. The median surgical urethral length (SUL) was significantly higher in the continent group (1050 vs. 1294 mm, p = 0.018). The urethral width measurements did not show a difference between the groups. In order to validate the Kinovea software as an accurate tool for the measurement of the urethral stump length and width results were correlated with the magnetic resonance imaging measurements of the urethra. CONCLUSIONS: The results of this study showed a significantly longer median SUL incontinent patients.

A Prospective, Observational, Multicentre Study Concerning Nontechnical Skills in Robot-assisted Radical Cystectomy Versus Open Radical Cystectomy.

INTRODUCTION AND HYPOTHESES: valuation of surgical skills, both technical and nontechnical, is possible through observations and video analysis. Besides technical failures, adverse outcomes in surgery can also be related to hampered communication, moderate teamwork, lack of leadership, and loss of situational awareness. Even though some surgeons are convinced about nontechnical skills being an important part of their professionalisation, there is paucity of data about a possible relationship between nontechnical skills and surgical outcome. In robot-assisted surgery, the surgeon sits behind the console and is at a remote position from the surgical field and team, making communication more important than in open surgery and conventional laparoscopy. A lack of structured research makes it difficult to assess the value of the different analysis methods for nontechnical skills, particularly in robot-assisted surgery. Our hypothesis includes the following: (1) introduction of robot-assisted surgery leads to an initial decay in nontechnical skills behaviour during the learning curve of the team, (2) nontechnical skills behaviour is more explicitly expressed in experienced robot-assisted surgery teams than in experienced open surgery teams, and (3) introduction of robot-assisted surgery leads to the development of different forms of nontechnical skills behaviour compared with open surgery. DESIGN: This study is a prospective, observational, multicentre, nonrandomised, case-control study including bladder cancer patients undergoing either an open radical cystectomy or a robot-assisted radical cystectomy at the Catharina Hospital Eindhoven, the Netherlands, or at the Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital Amsterdam. All patients are eligible for inclusion; there are no exclusion criteria. The Catharina Hospital Eindhoven, the Netherlands, performs on average 35 radical cystectomies a year. The Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital Amsterdam, performs on average 100 radical cystectomies a year. PROTOCOL OVERVIEW: The choice of treatment is at the discretion of the patient and the surgeon. Patient results will be obtained prospectively. Pathology results as well as complications occurring within 90 d following surgery will be registered. Surgical complications will be registered according to the Clavien-Dindo system. MEASUREMENTS: Nontechnical skills will be observed using five different methods: (1) NOTSS: Nontechnical Skills for Surgeons; (2) Oxford NOTECHS II: a modified theatre team nontechnical skills scoring system; (3) OTAS: Observational Teamwork Assessment for Surgery; (4) Interpersonal and Cognitive Assessment for Robotic Surgery (ICARS): evaluation of nontechnical skills in robotic surgery; and (5) analysis of human factors. Technical skills in robot-assisted radical cystectomy will be analysed using two different methods: (1) GEARS: Global Evaluative Assessment of Robotic Skill and (2) GERT: Generic Error Rating Tool. SAFETY CRITERIA AND REPORTING: Formal ethical approval has been provided by Medical research Ethics Committees United (MEC-U), The Netherlands (reference number W19.048). We hope to present the results of this study to the scientific community at conferences and in peer-reviewed journals. STATISTICAL ANALYSIS: Frequency statistics will be calculated for patient demographical data, and a Shapiro-Wilk test with p > 0.05 will be used to define normal distribution. Univariate analysis will be conducted to test for statistically significant differences in observation scores between open radical cystectomy and robot-assisted radical cystectomy cohorts across all variables, using independent sample t tests and Mann-Whitney U testing, as appropriate. A variable-selection strategy will be used to create multivariate models. Binary logistic regression will be conducted to calculate odds ratios and 95% confidence intervals for significant predictors on univariate analysis and clinically relevant covariates. Statistical significance is set at p < 0.05 based on a two-tailed comparison. SUMMARY: This study uses a structured approach to the analysis of nontechnical skills using extracorporeal videos of both open radical cystectomy and robot-assisted radical cystectomy surgeries, in order to obtain detailed data on nontechnical skills during open and minimally invasive surgeries. The results of this study could possibly be used to develop team-training programmes, specifically for the introduction of the surgical robot in relation to changes in nontechnical skills. Additional analysis of technical skills using the intracorporeal footage of the surgical robot will be used to elucidate the role of surgical skills and surgical events in nontechnical skills.

Analysis of the video motion tracking system "Kinovea" to assess surgical movements during robot-assisted radical prostatectomy.

BACKGROUNDS: Robot-assisted surgery facilitated the possibility to evaluate the surgeon's skills by recording and evaluating the robot surgical images. The aim of this study was to investigate the possibility of using a computer programme (Kinovea) for objective assessment of surgical movements in previously recorded in existing robot-assisted radical prostatectomy (RARP) videos. METHODS: Twelve entire RARP procedures were analysed by a trained researcher using the computer programme "Kinovea" to perform semi-automated assessment of surgical movements. RESULTS: Data analysis showed Kinovea was on average able to automatically assess only 22% of the total surgical duration per video of the robot-assisted surgery. On average, it lasted 4 hours of continued monitoring by the researcher to assess one RARP using Kinovea. CONCLUSION: Although we proved it is technically possible to use the Kinovea system in retrospective analysis of surgical movement in robot-assisted surgery, the acquired data do not give a comprehensive enough analysis of the video to be used in skills assessment.

The value of a 1-day multidisciplinary robot surgery training for novice robot surgeons.

INTRODUCTION: To fulfil the need for a basic level of competence in robotic surgery (Brinkman et al., Surg Endosc Other Interv Tech 31(1):281-287, 2017; Dutch Health inspectorate (Inspectie voor de gezondheidszorg), Insufficient carefulness at the introduction of surgical robots (in Dutch: Onvoldoende zorgvuldigheid bij introductie van operatierobots), Igz, Utrecht, 2010), the NIVEL (Netherlands Institute for Healthcare Research) developed the 'Basic proficiency requirements for the safe use of robotic surgery' (BPR). Based on the BPR a 1-day robotic surgery training was organised to answer the following research questions: (1) Are novice robot surgeons able to accurately self-assess their knowledge and dexterity skills? (2) Is it possible to include the teaching of all BPRs in a 1-day training? MATERIALS AND METHODS: Based on the BPR, a robot surgery course was developed for residents and specialists (surgery, gynaecology and urology). In preparation, the participants completed an online e-module. The 1-day training consisted of a practical part on robot set-up, a theoretical section, and hands-on exercises on virtual reality robot simulators. Multiple online questionnaire was filled out by the participants at the end of the training to evaluate the perceived educational value of the course and to self-assess the degree to which BPRs were reached. RESULTS: 20 participants completed the training during the conference of the Dutch Association for Endoscopic Surgery (NVEC) in 2017. Participants indicated nearly all competency requirements were mastered at the end of the training. The competency requirements not mastered were, however, critical requirements for the safe use of the surgical robot. Skill simulation results show a majority of participants are unable to reach a proficient simulation score in basic skill simulation exercises. CONCLUSION: Results show novice robot surgeons are too positive in the self-assessment of their own dexterity skills after a 1-day training. Self-assessment revealed uncertainty of the obtained knowledge level on requirements for the safe use of the surgical robot. Basic courses on robotic training should inform trainees about their results to enhance learning and inform them of their competence levels.

Results of the European Basic Laparoscopic Urological Skills examination.

BACKGROUND: In 2011, the European Basic Laparoscopic Urological Skills (E-BLUS) examination was introduced as a pilot for the examination of final-year urologic residents. OBJECTIVE: In this study, we aimed to answer the following research questions: What level of laparoscopic skills do final-year residents in urology have in Europe, and do the participants of the E-BLUS pass the examination according to the validated criteria? DESIGN, SETTING, AND PARTICIPANTS: Participants of the examination were final-year urology residents from different European countries taking part in the European Urology Residents Education Program in 2011 and 2012. SURGICAL PROCEDURE: The E-BLUS exam consists of five tasks validated for the training of basic urologic laparoscopic skills. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Performances of the tasks were recorded on DVD and analysed by an objective rater. Time and number of errors made in tasks 1-4 were noted. Furthermore, all expert laparoscopic urologists were asked to score participants on a global rating scale (1-5) based on three items: depth perception, bimanual dexterity, and efficiency. Participants were asked to complete a questionnaire on prior training and laparoscopic experience. RESULTS AND LIMITATIONS: Seventy DVD recordings were analysed. Most participants did not pass the time criteria on task 4 (90%), task 2 (85.7%), task 1 (74.3%), and task 5 (71.4%). Task 3 was passed by 84.3%. The overall quality score was passed by 64%. When combining time and quality, only three participants (4.2%) passed the examination according to the validated criteria. According to the questionnaire, 61% did not have the opportunity to train in laparoscopic skills. CONCLUSIONS: The results of the E-BLUS examination show that the level of basic laparoscopic skills among European residents is low. Although quality of performance is good, most residents do not pass the validated time criteria. Regular laparoscopic training or a dedicated fellowship should improve the laparoscopic level of residents in urology.

Evaluation of the educational value of a virtual reality TURP simulator according to a curriculum-based approach.

PURPOSE: This study aimed to evaluate the place of the TURPsim (Simbionix/VirtaMed, Beit Goal, Israel) within a urologic residency training curriculum, including training needs analysis (TNA) and investigating its validity. MATERIALS AND METHODS: Training needs analysis was conducted by an expert panel to identify procedural steps and pitfalls. Performance metrics of the simulator were compared with the TNA results. Participants were distributed according to their level of experience (completed transurethral resection of the prostate [TURP] procedures) as follows: novices (0), intermediates (1-50), and experts (>50). They followed standardized instructions and then performed 2 complete TURP procedures on the TURPsim. RESULTS: Ten of 22 procedural steps (TNA) and 4 of 11 pitfalls were covered by the TURPsim. A total of 66 participants, 22 in each group, were included. Median general judgment (face and content) about the TURPsim was rated 7.3 (median, 7; range, 3-9). Ninety-three percent of all participants qualified the TURPsim as a useful training model. Intermediates and experts had a significant faster resection time and less blood loss compared with novices (construct) (P = 0.001). Novices needed to re-resect previous lobes, and they also resected the prostate in the incorrect order more frequently compared with intermediates and experts. CONCLUSIONS: Training needs analysis is of paramount importance in the evaluation process of a training program. This curriculum-based approach including validity of a simulator seems valuable and may narrow the gap between skills laboratory and clinical practice. This study showed face, content, and construct validity of the TURPsim, and this simulator finds its place in the current urologic curriculum to train basic and procedural TURP skills.

da Vinci skills simulator for assessing learning curve and criterion-based training of robotic basic skills.

OBJECTIVE: To answer 2 research questions: what are the learning curve patterns of novices on the da Vinci skills simulator parameters and what parameters are appropriate for criterion-based robotic training. MATERIALS AND METHODS: A total of 17 novices completed 2 simulator sessions within 3 days. Each training session consisted of a warming-up exercise, followed by 5 repetitions of the "ring and rail II" task. Expert participants (n = 3) performed a warming-up exercise and 3 repetitions of the "ring and rail II" task on 1 day. We analyzed all 9 parameters of the simulator. RESULTS: Significant learning occurred on 5 parameters: overall score, time to complete, instrument collision, instruments out of view, and critical errors within 1-10 repetitions (P <.05). Economy of motion and excessive instrument force only showed improvement within the first 5 repetitions. No significant learning on the parameter drops and master workspace range was found. Using the expert overall performance score (n = 3) as a criterion (overall score 90%), 9 of 17 novice participants met the criterion within 10 repetitions. CONCLUSION: Most parameters showed that basic robotic skills are learned relatively quickly using the da Vinci skills simulator, but that 10 repetitions were not sufficient for most novices to reach an expert level. Some parameters seemed inappropriate for expert-based criterion training because either no learning occurred or the novice performance was equal to expert performance.