Evaluating robotic-assisted partial nephrectomy surgeons with fully convolutional segmentation and multi-task attention networks.

We use machine learning to evaluate surgical skill from videos during the tumor resection and renography steps of a robotic assisted partial nephrectomy (RAPN). This expands previous work using synthetic tissue to include actual surgeries. We investigate cascaded neural networks for predicting surgical proficiency scores (OSATS and GEARS) from RAPN videos recorded from the DaVinci system. The semantic segmentation task generates a mask and tracks the various surgical instruments. The movements from the instruments found via semantic segmentation are processed by a scoring network that regresses (predicts) GEARS and OSATS scoring for each subcategory. Overall, the model performs well for many subcategories such as force sensitivity and knowledge of instruments of GEARS and OSATS scoring, but can suffer from false positives and negatives that would not be expected of human raters. This is mainly attributed to limited training data variability and sparsity.

Toll-Like Receptor 4 Induction During Renal Ischemia Correlates with Serum Creatinine in a Pig Model.

Objectives: To determine whether toll-like receptor 4 (TLR4), a mediator of organ ischemia-reperfusion injury, is overexpressed during warm ischemia in a porcine solitary kidney model, and whether its expression correlates with creatinine, a surrogate for kidney function. Materials and Methods: Eight adult Yorkshire pigs underwent initial laparoscopic nephrectomy. After 1 week, animals were randomized into two groups: group 1 underwent laparoscopic renal hilar dissection, renal ischemia by cross-clamping, and reperfusion (ischemia group); group 2 underwent laparoscopic renal hilar dissection alone (sham group). Animals were survived to day 7 postrandomization. Peripheral blood was sampled for serum creatinine (sCr) and TLR4 expression at the following time points or corresponding intervals: prenephrectomy, 1-week postnephrectomy (preischemia), after 90 minutes of ischemia, 30 minutes postreperfusion, and at sacrifice. Intragroup TLR4 expression changes were analyzed using repeated measures ANOVA. Intergroup TLR4 expression was compared using Mann-Whitney's test. Correlation between sCr and TLR4 was assessed using Spearman's test. Results: Seven animals completed the experiment (four ischemia and three sham). Relative TLR4 expression significantly increased from baseline levels during ischemia, reperfusion, and sacrifice time points only in the ischemia group, and was significantly higher for the ischemia group after 90 minutes of ischemia (p = 0.034). sCr was significantly higher for the ischemia group during the reperfusion phase (p = 0.048). Relative TLR4 expression level significantly correlated with sCr in the overall cohort (Spearman's rho = 0.69) and in the ischemia group (Spearman's rho = 0.82; p < 0.0001 for each). Conclusions: Warm ischemia in a porcine solitary kidney induces acute overexpression of TLR4 in peripheral blood leukocytes, which is detectable. Relative TLR4 expression level strongly correlated with sCr but had an observable change sooner than change in sCr. Pending further investigation, TLR4 overexpression during renal ischemia may represent a sensitive quantitative marker of unilateral renal injury sustained during nephron-sparing surgery.

Evaluating Surgical Outcomes of Robot Assisted Simple Prostatectomy in the Retreatment Setting.

OBJECTIVE: To report perioperative and postoperative outcomes in men who undergo salvage RASP (sRASP) following some other endoscopic outlet procedure for benign prostate enlargement (BPE) compared to those undergoing RASP for primary treatment (pRASP). METHODS: A prospectively maintained database consisting of all RASP surgeries (December 2014-October 2019) performed at our institution by 3 different urologists was used. Patients who had received an endoscopic procedure for BPE prior to their RASP (sRASP) were compared to those who had not had a prior outlet procedure (pRASP). RESULTS: In total, 310 men underwent RASP during the study period. Of those, 30 (9.7%) had undergone an endoscopic procedure prior to surgery. There were no significant differences in age, race, ASA, BMI, prostate volume, PSA or rates of preoperative retention (P> .05 for all). Men who were treatment-naive had significantly higher preoperative International Prostate Symptom Scores (IPSS) than men who had a prior procedure (18.3 ± 7.7 vs 13.6 ± 6.2, P = .008). However, there were no significant differences in functional or quality of life outcomes between the 2 groups (P > .05 for all). There were no significant differences in perioperative or post-operative outcomes between the 2 groups. Furthermore, rates of post-operative complications and incontinence were similar between groups (11% vs 10%, P = .9 and 2% vs 0%, P = 1 respectively). CONCLUSION: Performing a RASP after prior endoscopic procedure for BPE was found to be safe and effective. Success and complication rates were similar to patients with no prior procedures.

Identifying predictors of antispasmodic use following robotic assisted simple prostatectomy.

INTRODUCTION: Anticholinergic or ß-3 agonist use following robotic simple prostatectomy (RASP) is not well described. We describe rates of antispasmodic use following RASP and identify potential predictors of medication use. MATERIALS AND METHODS: A retrospective review of all RASP patients from 2/2016 - 1/2020 was conducted. Patients with no preoperative International Prostate Symptom Score (IPSS) were excluded. Demographics, clinical data, and postoperative medication use were collected by electronic medical record review. Multivariable logistic regression analysis using a priori variables was performed to identify independent factors associated with antispasmodic use. RESULTS: A total of 255 patients underwent RASP at a mean age of 70.0 years ± 7.3 and mean body mass index (BMI) of 28.6 kg/m2 ± 5.0. Median preoperative prostate volume was 132.3 cc ± 45.0. Rates of preoperative diabetes, obstructive sleep apnea (OSA), smoking and alcohol use were 19.6%, 6.3%, 3.1%, and 11.8% respectively; 8.6% of patients (n = 22) initiated antispasmodics at a median of 2.5 months (IQR 1.3-4.2) postoperatively. Median duration of antispasmodic use was 6.5 months (IQR 1.7-14.7). Mirabegron was most commonly prescribed (31.8%). On multivariable logistic regression analysis, OSA was independently associated with postoperative antispasmodic use (OR 8.13, 95% CI 2.02-32.67, p = 0.003); 68.8% of OSA patients were treated with continuous positive airway pressure (CPAP). Treatment was not significantly associated with postoperative antispasmodic use (p = 0.61). CONCLUSION: Patients with OSA are over 8 times more likely to require antispasmodic medications following RASP in the short term. These patients may benefit from more tailored preoperative counseling.

Single-port robotic-assisted simple prostatectomy is associated with decreased post-operative narcotic use in a propensity score matched analysis.

Robotic-assisted simple prostatectomy (RASP) has proven to be an effective minimally invasive option for benign prostatic enlargement (BPE) in recent years. Single-site surgery is theorized to reduce post-operative pain beyond traditional minimally invasive approaches. We sought to assess whether use of a single-port robotic platform decreases post-operative opioid use in patients undergoing robotic-assisted simple prostatectomy (RASP). A retrospective review was performed of all patients undergoing RASP our institution from November 2017 to July 2019. Demographic, intraoperative, and post-operative data, including morphine equivalent (ME) use, were collected. Patients were stratified by robotic platform utilized. Propensity score matching using nearest neighbor method was performed using prostate volume, Charlson comorbidity index (CCI), and post-op ketorolac use in 4:1 fashion. Chi-squared analysis and Kruskal-Wallis analyses were utilized. Two-hundred-and-seven men underwent RASP. After matching, 80 patients (64 multi-port, 16 single-port) were included in the analysis. Groups were comparable for age, body mass index, CCI, prostate volume, prior opioid use, and use of scheduled ketorolac post op. The single-port approach was associated with a reduction in MEs once admitted to the floor (5 vs. 11 mg, p = 0.025) and an increase in the proportion of patients who did not require any narcotics post-operatively (44 vs. 19%, p = 0.036). In a propensity matched cohort of patients undergoing RASP at a single institution, use of the single-port robotic system conferred a significant decrease in post-operative narcotic use by approximately 50%.

Clinical Outcomes of Robotic Assisted Partial Nephrectomy for Pathologic T3a Renal Masses With Venous Tumor Thrombus.

OBJECTIVE: To evaluate the safety, efficacy, and early oncologic outcomes of pathologic T3a (pT3a) renal cell carcinoma with venous involvement treated with robotic partial nephrectomy (RPN), given that experience and outcomes in this group is limited. METHODS: A retrospective chart review of patients undergoing RPN from September 2009 to July 2020 was performed. Outcomes were captured from patients with pT3a disease with vein involvement. Clinical characteristics were analyzed using SPSS (IBM, Armonk, NY). Local recurrence-free survival and metastasis-free survival at 2 years were calculated from Kaplan-Meier survival curves. RESULTS: For 45 included patients, mean operative and warm ischemia times were 199.6 ± 47.3 minutes and 30.5 ± 10.5 minutes, with mean estimated blood loss of 324.9 ± 209.5 cc. Rates of transfusion, embolization, re-admission, and re-operation at 30 days were 8.9% (4/45), 2.2% (1/45), 11.1% (5/45), and 6.7% (3/45; cystoscopic stent placement), respectively. All tumors were malignant on pathology, with clear cell renal cell carcinoma being the most common (91.0%, n = 41). The positive margin rate was 6.7% (n = 3). Local recurrence occurred in 4.4% (n = 2) at a mean time of 5.2 ± 2.3 months. Four patients (8.9%) progressed to metastatic disease at a mean of 22.2 ± 23.0 months. At 2 years, local recurrence-free survival was 95.4% and metastasis-free survival was 95.3%. CONCLUSION: We present the largest known series of patients RPN for pT3a renal masses with venous tumor involvement. We found it both feasible and safe in the appropriate hands. Short term oncologic outcomes for these patients appear more favorable than historic literature suggested.

Evaluating robotic-assisted surgery training videos with multi-task convolutional neural networks.

We seek to understand if an automated algorithm can replace human scoring of surgical trainees performing the urethrovesical anastomosis in radical prostatectomy with synthetic tissue. Specifically, we investigate neural networks for predicting the surgical proficiency score (GEARS score) from video clips. We evaluate videos of surgeons performing the urethral anastomosis using synthetic tissue. The algorithm tracks surgical instrument locations from video, saving the positions of key points on the instruments over time. These positional features are used to train a multi-task convolutional network to infer each sub-category of the GEARS score to determine the proficiency level of trainees. Experimental results demonstrate that the proposed method achieves good performance with scores matching manual inspection in 86.1% of all GEARS sub-categories. Furthermore, the model can detect the difference between proficiency (novice to expert) in 83.3% of videos. Evaluation of GEARS sub-categories with artificial neural networks is possible for novice and intermediate surgeons, but additional research is needed to understand if expert surgeons can be evaluated with a similar automated system.

Irreversible Electroporation for the Treatment of Small Renal Masses: 5-Year Outcomes.

Introduction: Irreversible electroporation (IRE) is a nonthermal ablative technology that applies high-voltage short-pulse electrical current to create cellular membrane nanopores and ultimately results in apoptosis. This is thought to overcome thermal limitations of other ablative technologies. We report 5-year oncologic outcomes of percutaneous IRE for small renal masses. Patients and Methods: A single-institution retrospective review of cT1a renal masses treated with IRE from April 2013 to December 2019 was performed. Those with <1 month follow-up were excluded. IRE was performed with the NanoKnife© System (Angiodynamics, Latham, NY). Renal mass biopsy was obtained before or during ablation in most circumstances; biopsy was excluded in some patients because of concern for IRE probe displacement. Postablation guideline-based surveillance imaging was performed. Initial treatment failure was defined as persistent tumor enhancement on first post-treatment imaging. Survival analysis was performed through the Kaplan-Meier method for effectively treated tumors (SPSS; IBM, Armonk, NY). Results: IRE was used to treat 48 tumors in 47 patients. Twenty-two per 48 tumors (45.8%) were biopsy-confirmed renal cell carcinoma (RCC). No complications ≥ Clavien Grade III occurred and 36 patients (76.6%) were discharged the same day. Initial treatment success rate was 91.7% (n = 44/48); three treatment failures were managed with salvage radiofrequency ablation and one with robotic partial nephrectomy. Median follow-up was 50.4 months (interquartile range 29.0-65.5). The 5-year local recurrence-free survival was 81.4% in biopsy-confirmed RCC patients and 81.0% in all patients. Five-year metastasis-free survival was 93.3% and 97.1%, respectively, and 5-year overall survival was 92.3% and 90.6%, respectively. Five-year cancer-specific survival was 100% for both biopsy-confirmed RCC and all patient groups. Conclusions: IRE has low morbidity, but suboptimal intermediate-term oncologic outcomes compared with conventional thermal ablation techniques for small low-complexity tumors. Use of IRE should be restricted to select cases.

Use of Pre-operative Pharmacologic Venous Thromboembolism Prophylaxis for Robotic Partial Nephrectomy.

OBJECTIVE: To determine whether a single dose of preoperative enoxaparin for venous thromboembolism (VTE) prophylaxis impacts rates of thrombotic and bleeding events after robotic partial nephrectomy (RPNx). METHODS: A retrospective cohort study of RPNx patients from 2009 to 2020 was performed. Clinical characteristics and perioperative outcomes were compared between patients receiving a single dose of preoperative enoxaparin and those who did not. The primary outcome was 30-day hemorrhagic complications (transfusion ≥2 units, embolization, or reoperation for bleeding). Secondary outcomes were 30-day VTE events. Multivariable logistic regression was performed to control for significant differences between groups and to identify predictors of hemorrhagic complications among patients. RESULTS: Among 945 RPNx procedures, 794 (84%) received preoperative enoxaparin (PPx) and 151 (16%) did not (NPPx). The PPx cohort was older (P = .004), had lower BMI (P = .03), lower ASA class (P = .049), and fewer smokers (P = .03). Warm ischemia time was longer for PPx patients (P < .001). 4.9% and 2.6% of the PPx and NPPx cohorts, respectively, developed postoperative hemorrhagic complications (P = .29). After adjustment for potential covariates, pharmacologic prophylaxis was not associated with 30-day hemorrhagic complications (P = .39). On multivariable regression, longer warm ischemia time (OR 1.05, 95% CI 1.01-1.10, P = .02) and greater tumor size (OR 1.27, 95% CI 1.03-1.56, P = .02) were predictors of hemorrhagic complications. 30-day readmissions, VTE events, and mortality were similar between groups (all P> 0.05). CONCLUSION: Similar rates of thrombotic and bleeding events occurred between patients receiving pharmacologic prophylaxis and those who did not. Single dose of preoperative enoxaparin did not significantly alter perioperative outcomes after RPNx.

Single Port Robotic Surgery in Urology.

PURPOSE: To provide a comprehensive review on the new da Vinci SP (single port) robotic surgical system. The published literature to date within urology and a description of the new system will be discussed. FINDINGS: There are currently no high-quality published studies with the SP robotic system. All studies are case series, many with 10 or fewer patients. However, all studies have found the SP system to be safe and feasible in performing most urological procedures. Renal and pelvic surgery using the SP robotic system is safe and feasible in the hands of expert robotic surgeons. Long-term, high-quality data is lacking. While the current high price and the learning curve will limit the SP systems' use in many health care systems, new updates and the release of robotic surgical systems from other developers may help drive down costs and encourage uptake.

Experienced bedside-assistants improve operative outcomes for surgeons early in their learning curve for robot assisted laparoscopic radical prostatectomy.

Robot-assisted laparoscopic radical prostatectomy (RALP) relies heavily on the bedside assistant (BA). Currently, the relationship between BA experience and surgical outcomes in robotic surgery is not clear. We examined whether bedside assistant experience can significantly affect positive margin rate and peri-operative outcomes for RALP for surgeons within their learning curve. A retrospective cohort study of a single surgeon's peri-operative outcomes during RALP was examined and compared with and without an experienced bedside assistant. Patient demographic data and peri-operative data, margin rate, and length of stay (LOS), were collected and analyzed. Univariate and multivariable analyses were performed to determine if expert BA was a predictor of post-operative outcomes. In total, 170 consecutive cases over three years were analyzed. 111 (65%) were performed without an expert BA. The two groups were not significantly different with regards patient demographics (p > 0.05). On univariate analysis, having an expert BA was associated with a significantly lower LOS (31 h ± 21 vs. 42 h ± 26, p = 0.004), EBL (296 ml ± 180 vs. 441 ml ± 305, p < 0.0001) and positive margin rate (20% vs. 37%, p = 0.03). Other surgical outcomes were comparable between groups. On multivariable analysis, expert BA remained a predictor of, EBL (B stat = - 146, 95% CI - 240 to - 52, p = 0.003) and positive margin rate (OR 0.4, 95% CI 0.2-0.96, p = 0.04). Our results demonstrate that the use of an expert BA may result in improved patient outcomes early in the learning curve of RALP, most notably, positive margin rate and estimated blood loss.

Comprehensive assessment of the morbidity of renal mass biopsy: A population-based assessment of biopsy-related complications.

INTRODUCTION: We sought to assess seven-day and 30-day complications following renal mass biopsy (RMB), including mortality, hospitalizations, emergency department (ED) visits, and operative and non-operative complications and compare these to rates in population-matched controls. METHODS: We performed a population-based, matched, retrospective cohort study of patients undergoing RMB following consultation with a urologist and axial imaging from 2003-2015 in Ontario, Canada. Data on seven-day and 30-day rates of mortality, as well as operative and non operative complications after RMB were reported. The seven-day and 30-day rates of mortality, operative and non-operative interventions, hospitalizations, and ED visits were compared to matched controls using multivariable logistic regression. RESULTS: Among 6840 patients who underwent RMB in the study period, 24 (0.4%) and 159 (2.3%) died within seven and 30 days of their biopsy, respectively. Seven- and 30-day operative intervention rates were 79 (1.2%) and 236 (3.4%), respectively. Seven- and 30-day non-operative intervention rates were 227 (3.3%) and 529 (7.7%), respectively. Thirty-day mortality (odds ratio [OR] 8.1, 95% confidence interval [CI] 5.1-13.0), hospitalizations (OR 12.6, 95% CI 10.6-15.2), and ED visits (OR 3.8, 95% CI 3.4-4.3) were more common among patients who underwent RMB than the matched controls (p<0.001 for each). CONCLUSIONS: Patients undergoing RMB may have a small but non-negligible increased risk of mortality, hospital readmission, and ED visits compared to matched controls. However, limitations in the granularity of the dataset limits the strength of these conclusions. Further studies are needed to confirm our results. These risks should be discussed with patients for shared decision-making and considered in the risk/benefit tradeoff for the management of small renal masses.

Design and validation of a low-cost, high-fidelity model for robotic pyeloplasty simulation training.

INTRODUCTION/BACKGROUND: Owing to restrictions in operative experiences, urology residents can no longer solely rely on 'hands-on' operative time to master their surgical skills by the end of residency. Simulation training could help residents master basic surgical skills and steps of a procedure to maximize time in the operative room. However, simulators can be expensive or tedious to set up, limiting the availability to residents and training programs. OBJECTIVE: The authors sought to develop and validate an inexpensive, high-fidelity training model for robotic pyeloplasty. STUDY DESIGN: Pyeloplasty models were created using Dragon Skin® FX-Pro tissue-mimicking silicone cast over 3-dimensional molds. Urology faculty and trainees completed a demographic questionnaire. The participants viewed a brief instructional video and then independently performed robotic dismembered pyeloplasty on the model. Acceptability and content validity were evaluated via post-task evaluation of the model. Construct validity was evaluated by comparing procedure completion time, the Global Evaluative Assessment of Robotic Skills (GEARS) score, blinded subjective physical evaluation of repair quality (1-10 scale), and flow rate between experts and novices. RESULTS: In total, 5 urology faculty, 6 fellows, and 14 residents participated. The median robotic console experience among faculty, fellows, and residents was 8 years (interquartile range [IQR] = 6-11), 3.5 years (IQR = 2-4 years), and 0 years (IQR = 0-0.5 years), respectively. The median procedure completion time was 29 min (IQR = 26-40 min), and the median flow rate was 1.11 mL/s (IQR = 0-1.34 mL/s). All faculty had flow rates >1.25 mL/s and procedure times <30 min compared with 2 of 6 fellows and none of the residents (P < 0.001). All faculty, half of the fellows, and none of the residents achieved a GEARS score ≥20, with a median resident score of 12.5 (IQR = 8-13) (P < 0.001). For repair quality, all faculty scored ≥9 (out of 10), all fellows scored ≥8, and the median score among residents was 6 (IQR = 2-6) (P < 0.001). The material cost was $1.32/model, and the average production time was 0.12 person-hours/model. DISCUSSION AND CONCLUSION: This low-cost pyeloplasty model exhibits acceptability and content validity. Construct validity is supported by significant correlation between participant expertise and simulator performance across multiple assessment domains. The model has excellent potential to be used as a training tool in urology and allows for repetitive practice of pyeloplasty skills before live cases.

Robotic assisted extravascular stent placement for nutcracker phenomenon of the left renal vein: a case series.

Nutcracker phenomenon of the left renal vein is a rare anatomic anomaly that can present with chronic flank/pelvic pain, pelvic congestion, and hematuria. Conventional treatment options (superior mesenteric artery transposition, endovascular stent placement, auto-transplantation) involve substantial risk, morbidity, or the need for chronic anti-coagulation. We now report our institution's robotic experience with extravascular left renal vein stent placement. A retrospective, single surgeon series from December 2016 to May 2019 was reviewed. After positioning and port placement (three robotic ports, one assistant), the left renal vein was exposed and dissected free circumferentially down to the inferior vena cava insertion. The distance between the renal vein ostium and adrenal vein was measured and a 1 cm-diameter ringed polytetrafluoroethylene vascular stent of this length placed. The stent edges were secured to itself with 3-0 polyglactin sutures. Demographics, surgical, and functional outcomes were collected. Six patients with mean age of 45 ± 6 years and body mass index of 20.3 ± 3.3 g underwent the procedure. Mean operative time was 143 ± 20 min. Estimated blood loss was minimal. Mean graft length utilized was 2.25 ± 0.3 cm. Median day of discharge was 1.5 days (range 1-3). No high-grade complications occurred. All patients received immediate pain relief and 50% also saw other symptomatic improvements. Robotic assisted extravascular left renal vein stent placement appears safe and effective in a small cohort with short follow-up. Further long-term follow-up for pain relief and graft-related complications are needed.

Initial experience with extraperitoneal robotic-assisted simple prostatectomy using the da Vinci SP surgical system.

Robotic-assisted simple prostatectomy (RASP) has emerged as a safe and effective treatment option for symptomatic patients with lower urinary tract symptoms related to significant benign prostatic enlargement (BPE) above 80 g. The recent release of the da Vinci SP robotic system (Intuitive, Sunnyvale, CA, USA) continues to advance the minimally invasive nature of robotic surgical technology. We now report our institution's initial experience performing RASP using the da Vinci SP robotic system. An IRB-approved, retrospective chart review was performed of all patients undergoing robotic-assisted simple prostatectomy using the da Vinci SP surgical system in the treatment of benign prostatic enlargement by a single surgeon from March to June 2019. Pre-operative, intraoperative, and post-operative data were collected for descriptive analysis. A total of 10 men, mean age of 69 ± 4 years, with mean prostate volume of 104 ± 11 g underwent surgery. The robotic cannula and a single assistant port were utilized in all cases. No cases required conversion to a multi-port robotic platform or open approach, nor required the placement of additional assistant ports. No intraoperative or immediate post-operative complications were noted. Mean estimated blood loss was 141 ± 98 mL and operative time was 172 ± 19 min. Mean catheter time was 1.9 ± 1.8 days. One patient reported transient de novo stress urinary incontinence. Single-port RASP is a safe and effective intervention for BPE. The smaller surgical footprint from the device appears to make earlier catheter removal possible. Comparative evaluation with multi-port RASP and other modalities is warranted.

Brain activation during laparoscopic tasks in high- and low-performing medical students: a pilot fMRI study.

BACKGROUND: Up to 20% of medical students are unable to reach competency in laparoscopic surgery. It is unknown whether these difficulties arise from heterogeneity in neurological functioning across individuals. We sought to examine the differences in neurological functioning during laparoscopic tasks between high- and low-performing medical students using functional magnetic resonance imaging (fMRI). METHODS: This prospective cohort study enrolled North American medical students who were within the top 20% and bottom 20% of laparoscopic performers from a previous study. Brain activation was recorded using fMRI while participants performed peg-pointing, intracorporeal knot tying (IKT), and the Pictorial Surface Orientation (PicSOr) test. Brain activation maps were created and areas of activation were compared between groups. RESULTS: In total, 9/12 high and 9/13 low performers completed the study. High performers completed IKT faster and made more successful knot ties than low performers [standing: 23.5 (5.0) sec vs. 37.6 (18.4) sec, p = 0.03; supine: 23.2 (2.5) sec vs. 72.7 (62.8) sec, p = 0.02; number of successful ties supine, 3 ties vs. 1 tie, p = 0.01]. Low performers showed more brain activation than high performers in the peg-pointing task (q < 0.01), with no activation differences in the IKT task. There were no behavioral differences in the PiCSOr task. CONCLUSIONS: This study is the first to show differences between low and high performers of laparoscopic tasks at the brain level. This pilot study has shown the feasibility of using fMRI to examine laparoscopic surgical skills. Future studies are needed for further exploration of our initial findings.

A Cost-Utility Analysis of Nonsurgical Treatments for Stress Urinary Incontinence in Women.

OBJECTIVE: The objective of this study was to perform a cost-utility analysis of nonsurgical treatments for stress urinary incontinence (SUI) in healthy adult women with a health system perspective over a 1-year time horizon. METHODS: A decision tree model was constructed to evaluate the following nonsurgical treatment options for SUI in a simulated healthy adult female cohort who had failed Kegel exercises: pelvic floor muscle therapy (PFMT), a disposable tampon device (Impressa), a self-fitting intravaginal incontinence device (Uresta), and a traditional incontinence pessary. Published data and consultation with health care providers were used to estimate efficacies and costs. Health utility estimates were derived from existing literature. Deterministic sensitivity analyses were performed as well as Monte Carlo probabilistic sensitivity analysis to account for the impact of parameter uncertainty on costs and efficacies for each treatment. Our primary outcome was the highest net monetary benefit (NMB), which represents the monetary value of the health benefits less the treatment costs. The standard willingness-to-pay threshold of US $50,000 per quality-adjusted life year was used. RESULTS: The utility of SUI in an otherwise healthy patient was 0.81 ± 0.16 and for subjective cure was 0.93 ± 0.08. Using base-case estimates, PFMT was the most cost-effective treatment with an NMB of US $44,098. The Impressa tampon, Uresta, and traditional pessary had NMBs of US $43,970, $43,785, and $42,846, respectively. The probabilistic sensitivity analysis confirmed PFMT to be the most cost-effective treatment option at a willingness to pay of US $50,000 per quality-adjusted life year. CONCLUSIONS: The findings of our cost-utility analysis favor PFMT as the most cost-effective nonsurgical treatment option for SUI. Cost-effectiveness for 1 year of treatment was also favorable for Impressa and Uresta. In jurisdictions where there is no public funding for PFMT, Impressa or Uresta are alternatives for women wishing to avoid surgery.

The cost of treatment and its related complications for men who receive surgery or radiation therapy for prostate cancer.

INTRODUCTION: We sought to examine the costs related to treatment and treatment-related complications for patients treated with surgery or radiation for localized prostate cancer. METHODS: We performed a population-based, retrospective cohort study of men who underwent open radical prostatectomy or radiation from 2004-2009 in Ontario, Canada. Costs, including initial treatment and inpatient hospitalization, emergency room visit, outpatient consultation, physician billings, and medication costs, were determined for five years following treatment using a validated costing algorithm. Multivariable negative binomial regression was used to assess the association between treatment modality and costs. RESULTS: A total of 28 849 men underwent treatment for localized prostate cancer from 2004- 2009. In the five years following treatment, men who underwent radiation (n=12 675) had 21% higher total treatment and treatment-related costs than men who underwent surgery ($16 716/person vs. $13 213/person). Based on multivariable analysis, while men who underwent XRT had a lower relative cost in their first year after treatment (relative rate [RR] 0.97; 95% confidence interval [CI] 0.94-1.0; p=0.025), after year 2, annual costs were significantly higher in the radiation group compared to the surgery group (total cost for year 5, RR 1.44; 95% CI 1.17-1.76; p<0.0001). Our results were similar when restricted to young, healthy men and to older men. CONCLUSIONS: Men who undergo radiation have significantly higher five-year total treatment-related costs compared to men who undergo open radical prostatectomy. While surgery was associated with slightly higher initial costs, radiotherapy had higher costs in subsequent years.