RESUMO
OBJECTIVE: To describe the trocar disposition, docking angles, surgical times, functional outcomes and complications experienced during the first 30 surgeries with Hugo™ RAS platform performed by a high volume Da Vinci Xi®`s surgeon. METHODS: Retrospective, observational, descriptive study was performed between May-December 2023. Safety and feasibility of the procedures were evaluated considering console and docking time (min), perioperative complications (Clavien-Dindo classification), blood loss (mL), collision of the arms during the procedures (Yes/No). For radical prostatectomies (RARP) the urinary continence and sexual function were also evaluated. RESULTS: RARP, simple prostatectomies (RASP), partial nephrectomies (RAPN), and cystectomy (RARC) were performed. Trocar placement, docking, and bed assistant ergonomics were important challenges. Patient positioning, trocar placement, and robotic arm positioning had to be adapted. The median console operative time for RARP and RASP was 78 (60-120) minutes and 79 (58-125) minutes, respectively. The median docking time for both RARP and RASP was 10 (5-20) minutes. Of patients undergoing RARP, 94.5% recovered sexual function and no patient used more than one PAD per day after 90 days of the surgery. The median console operative and docking time for RAPN was 82 (80-130) minutes and 12 minutes (7-19) minutes, respectively. Blood loss in all patients was less than 200 mL and all none procedure presented major complications. CONCLUSION: For a high volume surgeon with motivated and well-trained multidisciplinary team, the implementation of HUGO™ RAS system for urological program is safe and smooth. Adaptations were necessary to achieve equivalent surgical technique and results. Docking position and bed assistant ergonomics are the major challenges.
RESUMO
ABSTRACT Purpose: To compare biochemical recurrence, sexual potency and urinary continence outcomes of ablative therapy and radical treatment (radical prostatectomy or radiotherapy with androgen deprivation therapy). Material and methods: A systematic review and meta-analysis followed the PRISMA guidelines were performed. We searched MEDLINE/PubMed. Biochemical recurrence at three and five years; incontinence rate (patients who used one pad or more) and erectile dysfunction rate at 12 and 36 months (patients who did not have sufficient erection to achieve sexual intercourse) were evaluated. The Mantel-Haenszel method was applied to estimate the pooled risk difference (RD) in the individual studies for categorical variables. All results were presented as 95% confidence intervals (95%CI). Random effects models were used regardless of the level of heterogeneity (I²). (PROSPERO CRD42022296998). Results: Eight studies comprising 2,677 men with prostate cancer were included. There was no difference in biochemical recurrence between ablative and radical treatments. We observed the same biochemical recurrence between ablative therapy and radical treatment within five years (19.3% vs. 16.8%, respectively; RD 0.07; 95%CI=-0.05, 0.19; I2=68.2%; P=0.08) and continence rate at 12 months (9.2% vs. 31.8%, respectively; RD −0.13; 95%CI, −0.27, 0.01; I2=89%; P=0.32). When focal treatment was analyzed alone, two studies with 582 patients found higher erectile function at 12 months in the ablative therapy group than in the radical treatment (88.9% vs. 30.8%, respectively; RD −0.45; 95%CI −0.84, −0.05; I2=93%; P=0.03). Conclusion: Biochemical recurrence and urinary continence outcomes of ablative therapy and radical treatment were similar. Ablative therapy appears to have a high rate of sexual potency.
RESUMO
ABSTRACT Introduction: Historically, therapeutic avenues for patients with clinical stage II seminoma germ cell tumors (SGCT) were confined to radiotherapy and chemotherapy. While survival rates with these modalities are commendable, both entail substantial long-term morbidities. Furthermore, this youthful patient cohort exhibits elevated rates of secondary malignancies, surfacing decades post-successful primary cancer treatment (1). Recently, retroperitoneal lymph node dissection (RPLND) has emerged as a primary treatment consideration for individuals with low-volume metastatic seminoma (2-4). However, there is a dearth of video documentation illustrating the robotic assisted (RA) bilateral approach (5- 7). Methods: We present the case of a 24-year-old male who underwent prior left orchiectomy for seminoma (pT1b). Despite negative serum tumor markers, a 1.7 x 1.4cm lymph node enlargement was identified in the aortic bifurcation after 4 months, classifying the patient as stage IIA per the IGCCCG risk classification. Subsequently, a RA bilateral template RPLND was performed due to the patient's refusal of chemotherapy, citing concerns about offspring. Results: The surgery was performed, incorporating nerve sparing techniques, lasting 4h13minutes, an estimated bleeding rate of 400ml, without intraoperative complications. The patient was discharged within 24 hours of the procedure, following a prescribed low-fat diet. Conclusion: The patient experienced postoperative well-being, painlessness, and resumed work three weeks post-procedure. Preserved ejaculation was noted, and adjuvant therapy was performed with 2 cycles of EP due to the anatomopathological result. The feasibility of robotic primary RPLND for SGCT was demonstrated, showing reduced postoperative pain and early hospital discharge. Further studies are necessary to validate our findings regarding oncological, safety, and functional outcomes.
RESUMO
PURPOSE: To compare biochemical recurrence, sexual potency and urinary continence outcomes of ablative therapy and radical treatment (radical prostatectomy or radiotherapy with androgen deprivation therapy). MATERIAL AND METHODS: A systematic review and meta-analysis followed the PRISMA guidelines were performed. We searched MEDLINE/PubMed. Biochemical recurrence at three and five years; incontinence rate (patients who used one pad or more) and erectile dysfunction rate at 12 and 36 months (patients who did not have sufficient erection to achieve sexual intercourse) were evaluated. The Mantel-Haenszel method was applied to estimate the pooled risk difference (RD) in the individual studies for categorical variables. All results were presented as 95% confidence intervals (95%CI). Random effects models were used regardless of the level of heterogeneity (I²). (PROSPERO CRD42022296998). RESULTS: Eight studies comprising 2,677 men with prostate cancer were included. There was no difference in biochemical recurrence between ablative and radical treatments. We observed the same biochemical recurrence between ablative therapy and radical treatment within five years (19.3% vs. 16.8%, respectively; RD 0.07; 95%CI=-0.05, 0.19; I2=68.2%; P=0.08) and continence rate at 12 months (9.2% vs. 31.8%, respectively; RD -0.13; 95%CI, -0.27, 0.01; I2=89%; P=0.32). When focal treatment was analyzed alone, two studies with 582 patients found higher erectile function at 12 months in the ablative therapy group than in the radical treatment (88.9% vs. 30.8%, respectively; RD -0.45; 95%CI -0.84, -0.05; I2=93%; P=0.03). CONCLUSION: Biochemical recurrence and urinary continence outcomes of ablative therapy and radical treatment were similar. Ablative therapy appears to have a high rate of sexual potency.
RESUMO
INTRODUCTION: Historically, therapeutic avenues for patients with clinical stage II seminoma germ cell tumors (SGCT) were confined to radiotherapy and chemotherapy. While survival rates with these modalities are commendable, both entail substantial long-term morbidities. Furthermore, this youthful patient cohort exhibits elevated rates of secondary malignancies, surfacing decades post-successful primary cancer treatment (1). Recently, retroperitoneal lymph node dissection (RPLND) has emerged as a primary treatment consideration for individuals with low-volume metastatic seminoma (2-4). However, there is a dearth of video documentation illustrating the robotic assisted (RA) bilateral approach (5- 7). METHODS: We present the case of a 24-year-old male who underwent prior left orchiectomy for seminoma (pT1b). Despite negative serum tumor markers, a 1.7 x 1.4cm lymph node enlargement was identified in the aortic bifurcation after 4 months, classifying the patient as stage IIA per the IGCCCG risk classification. Subsequently, a RA bilateral template RPLND was performed due to the patient's refusal of chemotherapy, citing concerns about offspring. RESULTS: The surgery was performed, incorporating nerve sparing techniques, lasting 4h13minutes, an estimated bleeding rate of 400ml, without intraoperative complications. The patient was discharged within 24 hours of the procedure, following a prescribed low-fat diet. CONCLUSION: The patient experienced postoperative well-being, painlessness, and resumed work three weeks post-procedure. Preserved ejaculation was noted, and adjuvant therapy was performed with 2 cycles of EP due to the anatomopathological result. The feasibility of robotic primary RPLND for SGCT was demonstrated, showing reduced postoperative pain and early hospital discharge. Further studies are necessary to validate our findings regarding oncological, safety, and functional outcomes.
Assuntos
Robótica , Seminoma , Neoplasias Testiculares , Humanos , Masculino , Adulto Jovem , Terapia Combinada , Excisão de Linfonodo , Seminoma/cirurgia , Neoplasias Testiculares/cirurgiaRESUMO
INTRODUCTION AND HYPOTHESIS: Pelvic organ prolapse (POP) is caused by an imbalance in the stability of the pelvic organs, resulting in loss of support. The most common types of POP, anterior and apical, are associated with lower urinary tract symptoms (LUTS) such as bladder outlet obstruction and detrusor overactivity (DO). Vaginal surgery may improve LUTS and overall urinary symptoms. We assessed urodynamic (UD) parameters and urinary symptoms before and after vaginal surgery for POP correction. METHODS: A prospective cohort of 59 women with symptomatic anterior and/or apical POP associated with urinary symptoms and with indications for vaginal surgery were included. POP surgeries included anterior colporrhaphy and vaginal hysterectomy with culdoplasty (VH) and with/without concomitant posterior colporrhaphy and mid-urethral sling (MUS). All participants underwent UD evaluation and answered urinary symptom questionnaires pre- and 3 months post-surgery. RESULTS: Anterior colporrhaphy was performed in all patients: 45.7% with associated VH and 54.2% with concomitant MUS. Preoperative ICIQ-OAB score >8 points was significantly associated with DO (p<0.02) and decreased after surgery (9±4.3 to 3.2±3.0, p<0.001). All other questionnaires demonstrated improvements in urinary symptoms. Stress urinary incontinence rate decreased from 59.6% to 21% (p<0.001). Post-void residual (PVR) volume and Valsalva maneuver also decreased (p<0.001). CONCLUSIONS: Pelvic organ prolapse surgery reduced the prevalence of urgency symptoms, and all questionnaires on urinary symptoms showed clinically significant improvement. Vaginal surgery for POP, even combined with MUS, significantly reduced PVR volume and improved urgency symptoms.
Assuntos
Sintomas do Trato Urinário Inferior , Prolapso de Órgão Pélvico , Incontinência Urinária por Estresse , Humanos , Feminino , Gravidez , Estudos Prospectivos , Resultado do Tratamento , Prolapso de Órgão Pélvico/complicações , Incontinência Urinária por Estresse/cirurgia , Colpotomia/efeitos adversos , Sintomas do Trato Urinário Inferior/cirurgia , Sintomas do Trato Urinário Inferior/complicaçõesRESUMO
ABSTRACT Introduction To evaluate the possible effects of the coronavirus disease 2019 (COVID-19) pandemic on the oncologic results of patients with prostate cancer regarding clinical staging, presence of adverse pathological outcomes, and perioperative complications. Materials and methods This retrospective study included patients who underwent radical prostatectomy. The time between biopsy and surgery, staging tests, final histopathological evaluation after surgery, lymphadenectomy rate, postoperative complications, and prostatic specific antigen (PSA) levels (initial and 30 days after surgery) were analyzed and compared in a group of patients before and during the pandemic period. Results We included 226 patients: 88 in the pre-pandemic period and 138 during the pandemic period. There was no statistically significant difference in mean age, body mass index, ASA, pathological locally advanced disease, the proportion of patients who underwent lymphadenectomy, and ISUP grade in the biopsy between the groups. Positive surgical margins, prostatic extracapsular extension, and PSA levels at 30 days were also similar between the groups. The mean time between medical consultation and surgery was longer in the pandemic period than in the pre-pandemic (124 vs. 107 days, p<0.001), and the mean time between biopsy and medical consultation (69.5 days vs. 114 days, p<0.001) and between biopsy and surgery (198.5 days vs. 228 days, p=0.013) was shorter during the pandemic. The incidence of severe early and late perioperative complications was similar between the periods. Conclusions There was no delay between diagnosis and treatment at our institution during the COVID-19 pandemic period. No worsening of the prostate cancer features was observed.
RESUMO
INTRODUCTION: To evaluate the possible effects of the coronavirus disease 2019 (COVID-19) pandemic on the oncologic results of patients with prostate cancer regarding clinical staging, presence of adverse pathological outcomes, and perioperative complications. MATERIALS AND METHODS: This retrospective study included patients who underwent radical prostatectomy. The time between biopsy and surgery, staging tests, final histopathological evaluation after surgery, lymphadenectomy rate, postoperative complications, and prostatic specific antigen (PSA) levels (initial and 30 days after surgery) were analyzed and compared in a group of patients before and during the pandemic period. RESULTS: We included 226 patients: 88 in the pre-pandemic period and 138 during the pandemic period. There was no statistically significant difference in mean age, body mass index, ASA, pathological locally advanced disease, the proportion of patients who underwent lymphadenectomy, and ISUP grade in the biopsy between the groups. Positive surgical margins, prostatic extracapsular extension, and PSA levels at 30 days were also similar between the groups. The mean time between medical consultation and surgery was longer in the pandemic period than in the pre-pandemic (124 vs. 107 days, p<0.001), and the mean time between biopsy and medical consultation (69.5 days vs. 114 days, p<0.001) and between biopsy and surgery (198.5 days vs. 228 days, p=0.013) was shorter during the pandemic. The incidence of severe early and late perioperative complications was similar between the periods. CONCLUSIONS: There was no delay between diagnosis and treatment at our institution during the COVID-19 pandemic period. No worsening of the prostate cancer features was observed.
Assuntos
COVID-19 , Neoplasias da Próstata , Masculino , Humanos , Antígeno Prostático Específico , Pandemias , Estudos Retrospectivos , COVID-19/patologia , Neoplasias da Próstata/patologia , Prostatectomia/métodos , Estadiamento de NeoplasiasAssuntos
Imageamento por Ressonância Magnética Multiparamétrica , Neoplasias da Próstata , Masculino , Humanos , Imageamento por Ressonância Magnética Multiparamétrica/métodos , Próstata/diagnóstico por imagem , Próstata/cirurgia , Próstata/patologia , Prostatectomia/métodos , Tomografia por Emissão de Pósitrons/métodos , Biópsia , Neoplasias da Próstata/diagnóstico por imagem , Neoplasias da Próstata/cirurgia , Neoplasias da Próstata/patologia , Imageamento por Ressonância Magnética/métodos , Tomografia por Emissão de Pósitrons combinada à Tomografia Computadorizada/métodosRESUMO
INTRODUCTION AND HYPOTHESIS: Pelvic organ prolapse (POP) is a defect of the female pelvic floor. Stress urinary incontinence (SUI), urge urinary incontinence (UUI), and obstructive symptoms may occur in these patients. The objective of surgical treatment is to restore the anatomy and function of the pelvic floor; however, it may prompt urinary symptoms not present previously. We performed a systematic review and meta-analysis to determine urodynamic changes in patients undergoing surgical correction for POP. METHODS: PubMed and Cochrane databases were searched for studies that contained data from urodynamic evaluation before and after vaginal surgery for POP. The main urodynamic data collected were free uroflowmetry (maximum flow [Qmax], voided volume, and post-void residual volume [PVR]), cystometry (bladder capacity, presence of detrusor overactivity [DO], SUI or UUI, and Valsalva leak point pressure), and pressure × flow study (detrusor pressure at maximum flow [PdetQmax], Qmax, and PVR). RESULTS: A total of 22 studies were included (1,549 women). Patients had a significantly higher prevalence of DO before surgery (OR = 1.56; 95% CI = 1.06-2.29), and surgeries without sling placement demonstrated a tendency to ameliorate DO. Patients who did not receive a sling were more incontinent after surgery. Bladder-emptying parameters improved after surgery, with higher PdetQmax before surgery (IV = 3.23; 95% CI = 0.45-1.18). Patients who did not receive MUS presented a lower Qmax (IV = -3.19; 95%CI = -4.09 to -2.30) and a higher PVR (IV = 27.89; 95%CI = 15.68-40.1) before surgery. CONCLUSION: Correction surgery for POP yields better urodynamic emptying parameters, with a reduction in the prevalence of DO. In contrast, sling placement enhances obstructive parameters.
Assuntos
Prolapso de Órgão Pélvico , Incontinência Urinária por Estresse , Humanos , Feminino , Urodinâmica , Micção , Prolapso de Órgão Pélvico/cirurgia , Incontinência Urinária por Estresse/cirurgia , Procedimentos Cirúrgicos Urológicos , Incontinência Urinária de UrgênciaRESUMO
INTRODUCTION: Non-metastatic, castration-resistant prostate cancer (nmCRPC) is an important clinical stage of prostate cancer, prior to morbidity and mortality from clinical metastases. In particular, the introduction of novel androgen-receptor signaling inhibitors (ARSi) has changed the therapeutic landscape in nmCRPC. Given recent developments in this field, we update our recommendations for the management of nmCRPC. METHODS: A panel of 51 invited medical oncologists and urologists convened in May of 2021 with the aim of discussing and providing recommendations regarding the most relevant issues concerning staging methods, antineoplastic therapy, osteoclast-targeted therapy, and patient follow-up in nmCRPC. Panel members considered the available evidence and their practical experience to address the 73 multiple-choice questions presented. RESULTS: Key recommendations and findings include the reliance on prostate-specific antigen doubling time for treatment decisions, the absence of a clear preference between conventional and novel (i.e., positron-emission tomography-based) imaging techniques, the increasing role of ARSis in various settings, the general view that ARSis have similar efficacy. Panelists highlighted the slight preference for darolutamide, when safety is of greater concern, and a continued need to develop high-level evidence to guide the intensity of follow-up in this subset of prostate cancer. DISCUSSION: Despite the limitations associated with a consensus panel, the topics addressed are relevant in current practice, and the recommendations can help practicing clinicians to provide state-of-the-art treatment to patients with nmCRPC in Brazil and other countries with similar healthcare settings.
Assuntos
Neoplasias de Próstata Resistentes à Castração , Neoplasias de Próstata Resistentes à Castração/diagnóstico , Neoplasias de Próstata Resistentes à Castração/terapia , Humanos , Masculino , Estadiamento de Neoplasias , Antineoplásicos/uso terapêutico , Antagonistas de Receptores de Andrógenos/uso terapêutico , Consenso , Brasil , OsteoclastosRESUMO
OBJECTIVE: To analyze the characteristics of public health services related to radical prostatectomy, according to hospital volume of surgeries and stratified as academic and non-academic centers. METHODS: An ecological study was conducted using a database available in TabNet platform of the Unified Health System Department of Informatics. Number of surgeries, length of hospital stay, length of stay in intensive care unit, in-hospital mortality rate, and cost of hospitalization were evaluated. The hospitals were divided into three subgroups according to surgery volume (tercile), and results were compared. The same comparisons were made among academic and non-academic centers. We considered academic centers those providing Urology residency program. RESULTS: A total of 11,259 radical prostatectomies were performed in the city of São Paulo between 2008 and 2018. We observed a significant trend of increase in radical prostatectomies for treating prostate cancer over the years (p=0.007). The length of stay in intensive care unit, and number of deaths were not statistically different among centers with diverse surgery volume, nor between academic and non-academic centers. However, length of hospital stay was significantly shorter in academic centers (p=0.043), while cost of hospitalization was significantly higher in high-volume center compared to low- (p<0.001) and intermediate-volume centers (p<0.001). CONCLUSION: Length of hospital stay for radical prostatectomies performed in public services in the city of São Paulo was shorter in academic centers, whereas hospitals with a high volume of surgeries showed greater cost of hospitalization.
Assuntos
Neoplasias da Próstata , Estados Unidos , Humanos , Masculino , Brasil/epidemiologia , Neoplasias da Próstata/cirurgia , Serviços de SaúdeRESUMO
ABSTRACT Introduction: We aimed to evaluate the role of remote proctoring during the initial training phases of a robotics curriculum using surgical robot skills simulator exercises. Materials and Methods: Prospective randomized study comprising 36 urology residents and junior staff urologists without previous robotic training. Group 1 (G1) performed exercises without any assistance or support, group 2 (G2) received support from in-person proctor, and group 3 (G3) from a remote proctor through a telementoring system. Qualitative and quantitative analyses were conducted for each exercise and group. Results: The overall score approval rates (OSA) for the different skill exercises were Ring Walk 2 (RW2) 83%, Energy Dissection 2 (ED2) 81%, and Ring Walk 3 (RW3) 14%. RW2 OSA was higher on attempt 3 than on attempt 1 (83.3% vs. 63.9%, p=0.032). ED2 OSA rate was higher in attempt 3 than in attempt 1 (80.6% vs. 52.8%, p=0.002). RW2 OSA was similar among the groups. In ED2, both remote and live assistance were significantly related to upper OSA (G1=47.2%, G2=75.0%, G3=83.3%, p=0.002). RW3 had similar OSA among the groups, which can be explained by the high level of difficulty and low OSA in all the groups. However, in a sensitive quantitative analysis, the mean overall score of the participants in RW3 was higher in both proctored groups (G1=24, G2=57.5, G3=51.5, p=0.042). Conclusion: Robotic performance increased significantly over three attempts for simulation exercises of low, medium, but not high-complexity. Proctoring, either in-person or remotely, has a positive impact on approval performance, particularly in intermediate tasks.
RESUMO
BACKGROUND: The aim of this study was to evaluate the current role of local treatment in prostate cancer with a low metastatic burden (or oligometastatic) in relation to survival and safety. METHODS: We performed a meta-analysis of studies published in the MEDLINE, EMBASE, and Cochrane databases until December 2021. Studies comparing local and nonlocal treatment in patients with metastatic prostate cancer were included. The risk of bias within studies was assessed using the Newcastle-Ottawa and Cochrane risk of bias tool. Oligo-metastasis was defined as low-volume metastasis with up to five lesions. The local treatment used was radical prostatectomy or external beam radiation therapy associated with systemic therapy (i.e., androgen deprivation therapy ± abiraterone, docetaxel, enzalutamide, or apalutamide). The endpoints evaluated were overall survival, cancer-specific survival, failure-free survival, and complication rates. RESULTS: Thirteen studies including 46,541 patients were included. The 5-year overall survival (16.0% vs. 6.5%, respectively; odds ratio (OR) 2.74; 95% confidence interval (CI), 2.18, 3.44; I2 = 0%; p < .00001) and 3-year cancer-specific survival (48.2% vs. 26.3%, respectively; OR 1.87; 95% CI: 1.44, 2.44; I2 = 0%; p < .00001) were higher in the local treatment group than that of the nonlocal treatment group. In addition, failure-free survival at 3 years was higher in the local treatment group than that of the nonlocal treatment group (40.5% vs. 28.4%, respectively; OR 1.72; 95% CI, 1.38, 2.14; I2 = 0%; p < .00001). The low complication rate of Clavien-Dindo grade ≥3 indicated that local treatment is feasible and safe in this setting. CONCLUSION: Recent data have shown that local treatment combined with systematic therapy, might improve the overall, cancer-specific, and failure-free survivals of patients diagnosed with metastatic prostate cancer. Furthermore, local treatment is both feasible and safe. Further studies evaluating the quality of life of these patients are needed.
Assuntos
Neoplasias da Próstata , Masculino , Humanos , Neoplasias da Próstata/radioterapia , Antagonistas de Androgênios/uso terapêutico , Qualidade de Vida , Prostatectomia , DocetaxelRESUMO
INTRODUCTION: We aimed to evaluate the role of remote proctoring during the initial training phases of a robotics curriculum using surgical robot skills simulator exercises. MATERIALS AND METHODS: Prospective randomized study comprising 36 urology residents and junior staff urologists without previous robotic training. Group 1 (G1) performed exercises without any assistance or support, group 2 (G2) received support from in-person proctor, and group 3 (G3) from a remote proctor through a telementoring system. Qualitative and quantitative analyses were conducted for each exercise and group. RESULTS: The overall score approval rates (OSA) for the different skill exercises were Ring Walk 2 (RW2) 83%, Energy Dissection 2 (ED2) 81%, and Ring Walk 3 (RW3) 14%. RW2 OSA was higher on attempt 3 than on attempt 1 (83.3% vs. 63.9%, p=0.032). ED2 OSA rate was higher in attempt 3 than in attempt 1 (80.6% vs. 52.8%, p=0.002). RW2 OSA was similar among the groups. In ED2, both remote and live assistance were significantly related to upper OSA (G1=47.2%, G2=75.0%, G3=83.3%, p=0.002). RW3 had similar OSA among the groups, which can be explained by the high level of difficulty and low OSA in all the groups. However, in a sensitive quantitative analysis, the mean overall score of the participants in RW3 was higher in both proctored groups (G1=24, G2=57.5, G3=51.5, p=0.042). CONCLUSION: Robotic performance increased significantly over three attempts for simulation exercises of low, medium, but not high-complexity. Proctoring, either in-person or remotely, has a positive impact on approval performance, particularly in intermediate tasks.