Robotic-Assisted Management of Ureteral Complications in Post-Renal Transplant Patients: A Case Series and Literature Review.

Introduction: Urologic complications are thought to be the most common surgical complication of renal transplantation. Ureteral pathology, including stenosis, urine leak, and vesicoureteral reflux, predominates. Although endourologic and interventional radiological management may be utilized, failure rates remain relatively high and surgical reconstruction remains the definitive management. Robotic ureteral reconstruction has been demonstrated to provide patient benefit in nontransplant populations, but the literature on transplant reconstruction is very limited. This study reports an additional series of patients with a focus on surgical technique, as well as reviews the available evidence for robotic reconstruction for post-transplant ureteral complications. Methods: All institutional patients undergoing robotic-assisted reconstruction for post-transplant ureteral complications for the years 2019-2022 were included. Intra- and postoperative variables, patient demographics, and follow-up data were obtained retrospectively from parsing of patient records. Statistics were tabulated descriptively. Results: Eleven patients underwent ureteral reconstruction. Of the 11, 9 (81%) were male with a mean age of 51.9 years (16-70) and BMI of 33.8 (24.3-49.1). The most common (10/11) indication for reconstruction was stricture; the most common (10/11) technique used was Lich-Gregoir reimplantation. Mean operative time was 288 minutes (143-500). There were no intra- or immediate postoperative complications. Median length of stay was 2 days (1-22). There were two incidences of mortality at 2 and 5 months postoperatively unrelated to surgery. There were four readmissions within 30 days, three for urinary tract infection (UTI) and one for a pelvic abscess which required washout. The remainder of the cohort has been followed for a mean of 14.6 months (6-41) without any incidences of graft loss or recurrence of ureteral pathology. Conclusions: Robotic-assisted ureteral reconstruction is a technically challenging but highly feasible technique that may provide the benefits of minimally invasive surgery while still allowing definitive reconstruction. Centers with extensive robotic capabilities should consider the technique.

Prostate Cancer Risk Stratification by Simple Scoring of the Current pT3 Lesions: A Proposal for a New Pathologic T-Staging System.

Cancer spread beyond the prostate, including extraprostatic extension (other than seminal vesicle or bladder invasion; EPE)/microscopic bladder neck invasion and seminal vesicle invasion (SVI) currently classified as pT3a and pT3b lesions, respectively, does not uniformly indicate poor oncologic outcomes. Accurate risk stratification of current pT3 disease is therefore required. We herein further determined the prognostic impact of these histopathologic lesions routinely assessed and reported by pathologists, particularly their combinations. We assessed consecutive 2892 patients undergoing radical prostatectomy for current pT2 (n = 1692), pT3a (n = 956), or pT3b (n = 244) disease at our institution between 2009 and 2018. Based on our preliminary findings, point(s) were given (1 point to focal EPE, microscopic bladder neck invasion, or unilateral SVI; 2 points to nonfocal/established EPE or bilateral SVI) and summed up in each case. Our cohort had 0 point (n = 1692, 58.5%; P0), 1 point (n = 243, 8.4%; P1), 2 points (n = 657, 22.7%; P2), 3 points (n = 192, 6.6%; P3), 4 points (n = 76, 2.6%; P4), and 5 points (n = 32, 1.1%; P5). Univariate analysis revealed associations of higher points with significantly worse biochemical progression-free survival, particularly when P4 and P5 were combined. In multivariable analysis (P0 as a reference), P1 (hazard ratio [HR], 1.57; P = .033), P2 (HR, 3.25; P < .001), P3 (HR, 4.01; P < .001), and P4 + P5 (HR, 5.99; P < .001) showed significance for the risk of postoperative progression. Meanwhile, Harrell C-indexes for the current pT staging, newly developed point system, and the Cancer of the Prostate Risk Assessment post-Surgical (CAPRA-S) score were 0.727 (95% CI, 0.706-0.748), 0.751 (95% CI, 0.729-0.773), and 0.774 (95% CI, 0.755-0.794), respectively, for predicting progression. We believe our data provide a logical rationale for a novel pathologic T-staging system based on the summed points, pT1a (0 point), pT1b (1 point), pT2 (2 points), pT3a (3 points), and pT3b (4 or 5 points), which more accurately stratifies the prognosis of prostate cancer.

Complications of single-port robot-assisted radical prostatectomy: multi-institutional analysis from the Single-Port Advanced Research Consortium (SPARC).

OBJECTIVE: To evaluate the perioperative complications of single-port robot-assisted radical prostatectomy (SP-RARP). PATIENTS AND METHODS: A retrospective review was performed on the prospectively maintained, Institutional Review Board-approved, multi-institutional Single-Port Advanced Research Consortium (SPARC) database. A total of 1103 patients were identified who underwent three different approaches of SP-RARP between 2019 and 2022 using the purpose-built SP robotic platform. In addition to baseline clinical, perioperative outcomes, this study comprehensively analysed for any evidence of intraoperative complication, as well as postoperative complication and readmission within 90 days of the respective surgery. RESULTS: Of the 244, 712, and 147 patients who underwent transperitoneal, extraperitoneal, and transvesical SP-RARP, respectively, intraoperative complications were noted in five patients (0.4%), all of which occurred during the transperitoneal approach. Two patients had bowel serosal tears, two had posterior button-holing of the bladder necessitating repair, and one patient had an obturator nerve injury. Postoperative complications were noted in 143 patients (13%) with major complications (Clavien-Dindo Grade ≥III) only identified in 3.7% of the total cohort. The most common complications were lymphocele (3.9%), acute urinary retention (2%), and urinary tract infection (1.9%). The 90-day re-admission rate was 3.9%. CONCLUSION: The SP-RARP is a safe and effective procedure with low complication and readmission rates regardless of the approach. These results are comparable to current multi-port RARP literature.

Can preoperative planning using IRIS™ three-dimensional anatomical virtual models predict operative findings during robot-assisted partial nephrectomy?

Objective: To evaluate the predictive validity of IRIS™ (Intuitive Surgical®, Sunnyvale, CA, USA) as a planning tool for robot-assisted partial nephrectomy (RAPN) by assessing the degree of overlap with intraoperative execution. Methods: Thirty-one patients scheduled for RAPN by four experienced urologists were enrolled in a prospective study. Prior to surgery, urologists reviewed the IRIS™ three-dimensional model on an iphone Operating System (iOS) app and completed a questionnaire outlining their surgical plan including surgical approach, and ischemia technique as well as confidence in executing this plan. Postoperatively, questionnaires assessing the procedural approach, clinical utility, efficiency, and effectiveness of IRIS™ were completed. The degree of overlap between the preoperative and intraoperative questionnaires and between the planned approach and actual execution of the procedure was analyzed. Questionnaires were answered on a 5-point Likert scale and scores of 4 or greater were considered positive. Results: Mean age was 65.1 years with a mean tumor size of 27.7 mm (interquartile range 17.5-44.0 mm). Hilar tumors consisted of 32.3%; 48.4% of patients had R.E.N.A.L. nephrometry scores of 7-9. On preoperative questionnaires, the surgeons reported that in 67.7% cases they were confident that they can perform the procedure successfully, and on intraoperative questionnaires, the surgeons reported that in 96.8% cases IRIS™ helped achieve good spatial sensation of the anatomy. There was a high degree of overlap between preoperative and intraoperative questionnaires for the surgical approach, interpreting anatomical details and clinical utility. When comparing plans for selective or off-clamp, the preoperative plan was executed in 90.0% of cases intraoperatively. Conclusion: A high degree of overlap between the preoperative surgical approach and intraoperative RAPN execution was found using IRIS™. This is the first study to evaluate the predictive accuracy of IRIS™ during RAPN by comparing preoperative plan and intraoperative execution.

Tracking health system performance in times of crisis using routine health data: lessons learned from a multicountry consortium.

COVID-19 has prompted the use of readily available administrative data to track health system performance in times of crisis and to monitor disruptions in essential healthcare services. In this commentary we describe our experience working with these data and lessons learned across countries. Since April 2020, the Quality Evidence for Health System Transformation (QuEST) network has used administrative data and routine health information systems (RHIS) to assess health system performance during COVID-19 in Chile, Ethiopia, Ghana, Haiti, Lao People's Democratic Republic, Mexico, Nepal, South Africa, Republic of Korea and Thailand. We compiled a large set of indicators related to common health conditions for the purpose of multicountry comparisons. The study compiled 73 indicators. A total of 43% of the indicators compiled pertained to reproductive, maternal, newborn and child health (RMNCH). Only 12% of the indicators were related to hypertension, diabetes or cancer care. We also found few indicators related to mental health services and outcomes within these data systems. Moreover, 72% of the indicators compiled were related to volume of services delivered, 18% to health outcomes and only 10% to the quality of processes of care. While several datasets were complete or near-complete censuses of all health facilities in the country, others excluded some facility types or population groups. In some countries, RHIS did not capture services delivered through non-visit or nonconventional care during COVID-19, such as telemedicine. We propose the following recommendations to improve the analysis of administrative and RHIS data to track health system performance in times of crisis: ensure the scope of health conditions covered is aligned with the burden of disease, increase the number of indicators related to quality of care and health outcomes; incorporate data on nonconventional care such as telehealth; continue improving data quality and expand reporting from private sector facilities; move towards collecting patient-level data through electronic health records to facilitate quality-of-care assessment and equity analyses; implement more resilient and standardized health information technologies; reduce delays and loosen restrictions for researchers to access the data; complement routine data with patient-reported data; and employ mixed methods to better understand the underlying causes of service disruptions.

Single-port Extraperitoneal and Transperitoneal Radical Prostatectomy: A Multi-Institutional Propensity-Score Matched Study.

OBJECTIVE: To compare the perioperative and early postoperative outcomes between single-port (SP) extraperitoneal radical prostatectomy (EPRP) and SP transperitoneal radical prostatectomy (TPRP), in a multi-institutional setting. METHODS: We identified all patients who underwent SP robot-assisted radical prostatectomy at 6 different institutes. Data of 650 patients were collected and divided into 2 groups based on the surgical approach: SP EPRP or SP TPRP. A Propensity-score matched-pair analysis for body mass index (BMI), prostate size, and National Comprehensive Cancer Network risk was performed with a 1:1 ratio. Analysis of perioperative and postoperative outcomes was performed using Wilcoxon signed-rank test and chi-square and Fisher's exact tests. RESULTS: After matching, 238 patients were included in each arm. The median follow-up period was 7 and 6 months for EPRP and TPRP groups, respectively. The total operative time was longer in the EPRP group (206 vs 155 minutes, P < .001). The EPRP group had a shorter length of hospitalization and same-day discharge rate compared to the TPRP approach (P < .001). There was no difference in the overall intraoperative or postoperative complications rate between the 2 groups, nor positive surgical margin rates. CONCLUSION: The SP extraperitoneal approach is associated with a shorter hospital stay and higher rate of same-day discharge, with no difference in the surgical margin, or complication rates.

Do Skills Naturally Transfer Between Multiport and Single-Port Robotic Platforms? A Comparative Study in a Simulated Environment.

Introduction and Objective: With introduction of the da Vinci single-port (SP) system, we evaluated which multiport (MP) robotic skills are naturally transferable to the SP platform. Methods: Three groups of urologists: Group 1 (5 inexperienced in MP and SP), Group 2 (5 experienced in MP without SP experience), and Group 3 (2 experienced in both MP and SP) were recruited to complete a validated urethrovesical anastomosis simulation using MP followed by SP robots. Performance was graded using both GEARS and RACE scales. Subjective cognitive load measurements (Surg-TLX and difficulty ratings [/20] of instrument collisions camera and EndoWrist movement) were collected. Results: GEARS and RACE scores for Groups 1 and 3 were maintained on switching from MP to SP (Group 3 scored significantly higher on both systems). Surg-TLX and difficulty scores were also maintained for both groups on switching from MP and SP except for a significant increase in SP camera movement (+7.2, p = 0.03) in Group 1 compared to Group 3 that maintained low scores on both. Group 2 demonstrated significant lower GEARS (-2.9, p = 0.047) and RACE (-5.1, p = 0.011) scores on SP vs MP. On subanalysis, GEARS subscores for force sensitivity and robotic control (-0.7, p = 0.04; -0.9, p = 0.02) and RACE subscores for needle entry, needle driving, and tissue approximation (-0.9, p = 0.01; -1.0, p = 0.02; -1.0, p < 0.01) significantly decreased. GEARS (depth perception, bimanual dexterity, and efficiency) and RACE subscores (needle positioning and suture placement) were maintained. All participants scored significantly lower in knot tying on the SP robot (-1.0, p = 0.03; -1.2, p = 0.02, respectively). Group 2 reported higher Surg-TLX (+13 pts, p = 0.015) and difficulty ratings on SP vs MP (+11.8, p < 0.01; +13.6, p < 0.01; +14 pts, p < 0.01). Conclusions: The partial skill transference across robots raises the question regarding SP-specific training for urologists proficient in MP. Novices maintained difficulty scores and cognitive load across platforms, suggesting that concurrent SP and MP training may be preferred.

Da Vinci SP radical prostatectomy: a multicentric collaboration and step-by-step techniques

ABSTRACT Introduction Several techniques of robotic-assisted radical prostatectomy (RARP) using the da Vinci SP (SP) have been described since its clearance by the FDA (Food and Drug Administration) in 2018 ( 1 , 2 ). Even with the expanding literature about this robot, the SP technology has been restricted to a few centers in the US and Asia due to the recent release of this robot in the marked.3 In this scenario, we provided, in this video compilation, a consensus of SP referral centers describing the current approaches and techniques of da Vinci SP Radical prostatectomy (SP-RARP). Surgical Technique We have illustrated five different techniques, including transperitoneal, extraperitoneal, Retzius-sparing, transvesical, and transperineal ( 4 - 6 ). Each surgery demonstrated crucial steps from the trocar placement until anastomosis. All approaches follow anatomic concepts and landmarks to minimize positive surgical margins, optimize oncological outcomes and promote optimal functional recovery. The trocar placement and the use of an assistant port were selected according to the operative technique of each institution. None of these surgeries had intra- or postoperative complications, and the pain management until discharge was controlled without using narcotics. All patients were discharged in less than 16 hours of surgery. Conclusion Robotic-assisted radical prostatectomy performed with the da Vinci SP is feasible and safe with optimal perioperative outcomes. Five different approaches were described in this video compilation, and we believe that the technical details provided by this multicentric collaboration are crucial for centers willing to initiate the SP approach to radical prostatectomy.

Contemporary techniques of da Vinci SP radical prostatectomy: multicentric collaboration and expert opinion

ABSTRACT Background The da Vinci SP robot consists of an innovative single port trocar that houses a flexible camera and three biarticulated arms, which minimizes the number of incisions to assess the surgical site, allowing a less invasive procedure. However, due to its recent release in the market, the current literature reporting SP-RARP is still restricted to a few centers. In this scenario, after performing a literature search with all available techniques of SP-RARP, our objective is to report a multicentric opinion of referral centers on different techniques to approach SP-RARP. Results The SP literature is provided by only a few centers due to the limited number of this new console in the market. Five different approaches are available: transperitoneal, extraperitoneal, Retzius-Sparing, transperineal and transvesical. None of the current studies describe long-term functional or oncological outcomes. However, all approaches had satisfactory operative performance with minimum complication rates. Conclusions Several techniques of SP-RARP have been reported in the literature. We performed a multicentric collaboration describing and illustrating the most challenging steps of this surgery. We believe that the details provided in this article are useful teaching material for new centers willing to adopt the SP technology.

Operative Planning of Chest Wall Reconstructions Illustrated by a Large Defect in a Child.

Reconstruction of large chest wall defects is challenging. Here we discuss the process of decision-making in planning chest wall reconstruction, considering the requirements of tumor removal, stabilization of the chest wall, and soft tissue coverage, illustrated by a case of a hemi-chest wall defect in a child. Ewing sarcoma measuring 10 × 9 × 13 cm was resected in a 9-year-old boy, followed by stabilization using a Gore-Tex patch. Due to extension of the oncologic resection far into the superomedial quadrant of the chest, tension-free coverage with a classical latissimus-dorsi flap could not be achieved. Integrating the serratus-anterior muscle into the flap creating a chimeric latissimus-dorsi/serratus-anterior flap allowed for excellent soft tissue coverage of the foreign body. As the skin could be preserved, careful incision planning was necessary to allow for best possible exposure during oncologic resection and flap harvest, while ensuring skin vascularization impaired by underlying tumor resection. Two vertical skin incisions were chosen, one presternal and a second in the mid-axillary fold delineating a large bipedicled skin flap. Postoperative recovery was excellent. Solid skin vascularization and adequate soft tissue coverage of the alloplastic material allowed for the patient to receive two cycles of postoperative radiotherapy without developing wound dehiscence. Careful interdisciplinary planning of skin incisions allowed for good exposure for tumor resection and flap harvest while preserving skin vascularization. Choosing a chimeric latissimus-dorsi/serratus-anterior flap provided larger coverage than a classical latissimus-dorsi flap with minimal additional donor site morbidity. Taken together, we here present a pragmatic solution to a complex problem.

Medicare Accountable Care Organizations: Post-acute Care Use and Post-surgical Outcomes in Urologic Cancer Surgery.

OBJECTIVE: To evaluate association between Medicare accountable care organizations (ACOs) participation of hospitals on post-acute care (PAC) use and spending, and post-surgical outcomes in Medicare beneficiaries undergoing urologic cancer surgeries. Despite increasing prevalence of urologic cancer and surgical care contributing to a large proportion of total health care costs, and recent Medicare payment reforms such as accountable care organizations, the role of ACOs in urologic cancer care has been unexplored. METHODS: We conducted a longitudinal analysis of 2011-2017 Medicare claims data to compare post-surgical outcomes between Medicare ACO and non-ACO patients before and after implementation of Medicare shared savings program (MSSP). Our outcomes of interest were Post-acute care (PAC) use (overall, institutional, and home health), Skilled Nursing Facility (SNF) length of stay and Medicare spending for SNF patients, 30-day and 90-day unplanned readmissions and complications after index procedure. RESULTS: Study sample included a total of 334,514 Medicare patients undergoing bladder, prostate, kidney cancer surgeries at 524 Medicare ACO and 2066 non-ACO hospitals. For bladder cancer surgery, Medicare ACO participation was associated with significantly reduced overall post-acute care use, but not with changes in readmission or complication rate. For prostate cancer and kidney cancer surgery, we found no significant association between hospital participation in Medicare ACOs and PAC use or post-surgical outcomes. CONCLUSION: Hospital participation in MSSP ACOs leads to lower post-acute care use without compromising patient outcomes for Medicare beneficiaries undergoing bladder cancer surgery. Future research is needed to understand longer-term impact of ACO participation on urologic cancer surgery outcomes.

Standard Multiport vs Single-Port Robot-Assisted Simple Prostatectomy: A Single-Center Initial Experience.

Background: Robot-assisted simple prostatectomy (RASP) has emerged as a safe surgical treatment for patients with benign prostatic hyperplasia with large glands (>80 mL). Several studies reported on perioperative outcomes of RASP by the standard multiport (MP) da Vinci® robotic system approach. Studies conducted on RASP utilizing the novel single-port (SP) da Vinci SP robotic platform (Intuitive Surgical, Sunnyvale, CA) are scarce. We aimed to compare intraoperative and short-term postoperative outcomes between the da Vinci MP and SP robots for patients undergoing RASP in a referral center. Methods: In this retrospective study, we reviewed all patients who underwent RASP using MP or SP robot from September 2016 to March 2021. Intraoperative data, overall 30-day complications, complications by Clavien-Dindo classification, and 90-day readmission and reoperation rates were assessed and compared between the two groups using appropriate statistical methods. Results: Seventy-five patients who underwent RASP were identified. Of these, 47 were in the MP group and 28 were in the SP. Compared with SP, mean operative time in MP group was 216.6 vs 232.4 minutes (p = 0.39), estimated blood loss was 195.7 vs 227.1 mL (p = 0.43), and length of stay was 2 vs 2.5 days (p = 0.45). There was a trend toward higher overall complication rate in SP group vs MP (42.86% vs 21.28%, p = 0.09). There were no significant differences in the readmission (17.02% vs 10.71%, p = 0.52) and reoperation (2.1% vs 7.14%, p = 0.34) rates between MP vs SP group. Conclusion: SP-RASP is safe and shows equivalent perioperative outcomes when compared with the MP robotic system. A marginal increase of complication rate was recorded in the SP group; however, this did not demonstrate statistical significance.

Contemporary techniques of da Vinci SP radical prostatectomy: multicentric collaboration and expert opinion.

BACKGROUND: The da Vinci SP robot consists of an innovative single port trocar that houses a flexible camera and three biarticulated arms, which minimizes the number of incisions to assess the surgical site, allowing a less invasive procedure. However, due to its recent release in the market, the current literature reporting SP-RARP is still restricted to a few centers. In this scenario, after performing a literature search with all available techniques of SP-RARP, our objective is to report a multicentric opinion of referral centers on different techniques to approach SP-RARP. RESULTS: The SP literature is provided by only a few centers due to the limited number of this new console in the market. Five different approaches are available: transperitoneal, extraperitoneal, Retzius-Sparing, transperineal and transvesical. None of the current studies describe long-term functional or oncological outcomes. However, all approaches had satisfactory operative performance with minimum complication rates. CONCLUSIONS: Several techniques of SP-RARP have been reported in the literature. We performed a multicentric collaboration describing and illustrating the most challenging steps of this surgery. We believe that the details provided in this article are useful teaching material for new centers willing to adopt the SP technology.

Da Vinci SP radical prostatectomy: a multicentric collaboration and step-by-step techniques.

INTRODUCTION: Several techniques of robotic-assisted radical prostatectomy (RARP) using the da Vinci SP (SP) have been described since its clearance by the FDA (Food and Drug Administration) in 2018 (1, 2). Even with the expanding literature about this robot, the SP technology has been restricted to a few centers in the US and Asia due to the recent release of this robot in the marked.3 In this scenario, we provided, in this video compilation, a consensus of SP referral centers describing the current approaches and techniques of da Vinci SP Radical prostatectomy (SP-RARP). SURGICAL TECHNIQUE: We have illustrated five different techniques, including transperitoneal, extraperitoneal, Retzius-sparing, transvesical, and transperineal (4-6). Each surgery demonstrated crucial steps from the trocar placement until anastomosis. All approaches follow anatomic concepts and landmarks to minimize positive surgical margins, optimize oncological outcomes and promote optimal functional recovery. The trocar placement and the use of an assistant port were selected according to the operative technique of each institution. None of these surgeries had intra- or postoperative complications, and the pain management until discharge was controlled without using narcotics. All patients were discharged in less than 16 hours of surgery. CONCLUSION: Robotic-assisted radical prostatectomy performed with the da Vinci SP is feasible and safe with optimal perioperative outcomes. Five different approaches were described in this video compilation, and we believe that the technical details provided by this multicentric collaboration are crucial for centers willing to initiate the SP approach to radical prostatectomy.

COVID-19 and resilience of healthcare systems in ten countries.

Declines in health service use during the Coronavirus Disease 2019 (COVID-19) pandemic could have important effects on population health. In this study, we used an interrupted time series design to assess the immediate effect of the pandemic on 31 health services in two low-income (Ethiopia and Haiti), six middle-income (Ghana, Lao People's Democratic Republic, Mexico, Nepal, South Africa and Thailand) and high-income (Chile and South Korea) countries. Despite efforts to maintain health services, disruptions of varying magnitude and duration were found in every country, with no clear patterns by country income group or pandemic intensity. Disruptions in health services often preceded COVID-19 waves. Cancer screenings, TB screening and detection and HIV testing were most affected (26-96% declines). Total outpatient visits declined by 9-40% at national levels and remained lower than predicted by the end of 2020. Maternal health services were disrupted in approximately half of the countries, with declines ranging from 5% to 33%. Child vaccinations were disrupted for shorter periods, but we estimate that catch-up campaigns might not have reached all children missed. By contrast, provision of antiretrovirals for HIV was not affected. By the end of 2020, substantial disruptions remained in half of the countries. Preliminary data for 2021 indicate that disruptions likely persisted. Although a portion of the declines observed might result from decreased needs during lockdowns (from fewer infectious illnesses or injuries), a larger share likely reflects a shortfall of health system resilience. Countries must plan to compensate for missed healthcare during the current pandemic and invest in strategies for better health system resilience for future emergencies.

Utilizing head-mounted eye trackers to analyze patterns and decision-making strategies of 3D virtual modelling platform (IRIS™) during preoperative planning for renal cancer surgeries.

PURPOSE: IRIS™ provides interactive, 3D anatomical visualizations of renal anatomy for pre-operative planning that can be manipulated by altering transparency, rotating, zooming, panning, and overlaying the CT scan. Our objective was to analyze how eye tracking metrics and utilization patterns differ between preoperative surgical planning of renal masses using IRIS and CT scans. METHODS: Seven surgeons randomly reviewed IRIS and CT images of 9 patients with renal masses [5 high complexity (RENAL score ≥ 8), 4 low complexity (≤ 7)]. Surgeons answered a series of questions regarding patient anatomy, perceived difficulty (/100), confidence (/100), and surgical plan. Eye tracking metrics (mean pupil diameter, number of fixations, and gaze duration) were collected. RESULTS: Surgeons spent significantly less time interpreting data from IRIS than CT scans (- 67.1 s, p < 0.01) and had higher inter-rater agreement of surgical approach after viewing IRIS (α = 0.16-0.34). After viewing IRIS, surgical plans although not statistically significant demonstrated a greater tendency towards a more selective ischemia approaches which positively correlated with improved identification of vascular anatomy. Planned surgical approach changed in 22/59 of the cases. Compared to viewing the CT scan, left and right mean pupil diameter and number/duration of fixations were significantly lower when using IRIS (p < 0.01, p < 0.01, p = 0.42, p < 0.01, respectively), indicating interpreting information from IRIS required less mental effort despite under-utilizing its interactive features. CONCLUSIONS: Surgeons extrapolated more detailed information in less time with less mental effort using IRIS than CT scans and proposed surgical approaches with potential to enhanced surgical outcomes.

TWIST1 expression is associated with high-risk neuroblastoma and promotes primary and metastatic tumor growth.

The embryonic transcription factors TWIST1/2 are frequently overexpressed in cancer, acting as multifunctional oncogenes. Here we investigate their role in neuroblastoma (NB), a heterogeneous childhood malignancy ranging from spontaneous regression to dismal outcomes despite multimodal therapy. We first reveal the association of TWIST1 expression with poor survival and metastasis in primary NB, while TWIST2 correlates with good prognosis. Secondly, suppression of TWIST1 by CRISPR/Cas9 results in a reduction of tumor growth and metastasis colonization in immunocompromised mice. Moreover, TWIST1 knockout tumors display a less aggressive cellular morphology and a reduced disruption of the extracellular matrix (ECM) reticulin network. Additionally, we identify a TWIST1-mediated transcriptional program associated with dismal outcome in NB and involved in the control of pathways mainly linked to the signaling, migration, adhesion, the organization of the ECM, and the tumor cells versus tumor stroma crosstalk. Taken together, our findings confirm TWIST1 as promising therapeutic target in NB.

Design and Implementation of an Emergency Undocking Curriculum for Robotic Surgery.

INTRODUCTION: Current training for robotic surgery crisis management, specifically emergency robotic undocking protocol (ERUP), remains limited to anecdotal experience. A curriculum to impart the skills and knowledge necessary to recognize and complete a successful ERUP was developed using an education approach then evaluated. METHODS: Baseline knowledge and confidence regarding ERUP were established for 5 robotic teams before completing 2 full-immersion simulations separated by an online self-paced learning module. In each simulation, teams operated on a perfused hydrogel model and were tasked to dissect a retroperitoneal tumor abutting a major vessel. During vascular pedicle ligation, a major vascular bleed and nonrecoverable robotic fault were remotely induced, necessitating ERUP with open conversion. After the simulation, participants completed surgery task load index (cognitive load assessment) and realism surveys. Weighted checklists scored participants' actions during each simulation. Surgical metrics including estimated blood loss, time to control bleeding, and undocking time were recorded. Curriculum retention was assessed by repeating the exercise at 6 months. RESULTS: Participants experienced high levels of cognitive demand and agreed that the simulation's realism and stress mimicked live surgery. Longitudinal analysis showed significant knowledge (+37.5 points, p = 0.004) and confidence (+15.3 points, p < 0.001) improvements from baseline to completion. Between simulations, checklist errors, undocking time, and estimated blood loss decreased (38⇾17, -40 seconds, and -500 mL, respectively), whereas action scores increased significantly (+27 points, p = 0.008). At 6 months, insignificant changes from curriculum completion were seen in knowledge (-4.8 points, p = 0.36) and confidence (+3.7 points, p = 0.1). CONCLUSIONS: This simulation-based curriculum successfully improves operative team's confidence, knowledge, and skills required to manage robotic crisis events.

Greater Risk of Pregnancy Complications for Female Surgeons: A Cross-Sectional Electronic Survey.

BACKGROUND: Female surgeons are exposed to physical and mental stressors that differ from those of other specialties. We aimed to assess whether female surgeons are more at risk of pregnancy complications than women in other medical specialties. METHODS: We used a cross-sectional electronic survey of female physicians working in the French Region Nouvelle-Aquitaine who were pregnant between 2013 and 2018. A pregnancy complication was defined as the occurrence of miscarriage, ectopic pregnancy, fetal growth restriction, prematurity, fetal congenital malformation, stillbirth, or medical termination of the pregnancy. Multivariate logistic regression models were used to evaluate the risk of pregnancy complications for female surgeons relative to women practicing in other medical specialties. RESULTS: Among the 270 women included, 52 (19.3%) experienced pregnancy complications and 28 (10.4%) were surgeons. In the multivariate analysis, female surgeons had a higher risk of pregnancy complications: adjusted odds ratio = 3.53, 95% confidence interval [1.27-9.84]. CONCLUSION: Further research is necessary to identify the hazards specifically involved in the practice of surgery to be able to propose preventive actions targeted to female surgeons during their pregnancy.

Extraperitoneal Single-Port Robot-Assisted Radical Prostatectomy.

Robot-assisted radical prostatectomy (RARP) is currently the standard minimally invasive procedure for the surgical management of localized prostate cancer. It has been shown that the minimally invasive robotic approach offers comparable oncologic and functional outcomes with potential advantages, including decreased blood loss, shorter hospital stay, and recovery period when compared with open surgery. Generally, the transperitoneal RARP approach is the most commonly performed among robotic surgeons, owing to its wider space and early adoption. However, similar oncologic outcomes have been reported with the extraperitoneal approach. Owing to its perceived technical difficulty, extraperitoneal RARP is less adopted nowadays. This approach, however, has its merits particularly in cases where intraperitoneal access can be problematic with extensive adhesions from previous surgeries. Also, extraperitoneal approach allows for minimal bowel manipulation, less steep Trendelenburg positioning, and less pneumoperitoneum, which reflect on early recovery of bowel function after RARP. Both transperitoneal and extraperitoneal approaches can be performed using either the conventional multiport robotic system or the more recent single-port (SP) robotic system. With respect to extraperitoneal RARP, there has been an increased adoption of the SP system, with purported advantages such as better cosmesis, less postoperative analgesic and opioid requirements, and shorter duration of hospital stay. Herein, we describe the technical steps relevant to extraperitoneal single-port robot-assisted radical prostatectomy, and elaborate on the clinical outcomes reported in the literature.