An Assessment Tool to Provide Targeted Feedback to Robotic Surgical Trainees: Development and Validation of the End-To-End Assessment of Suturing Expertise (EASE).

Purpose: To create a suturing skills assessment tool that comprehensively defines criteria around relevant sub-skills of suturing and to confirm its validity. Materials and Methods: 5 expert surgeons and an educational psychologist participated in a cognitive task analysis (CTA) to deconstruct robotic suturing into an exhaustive list of technical skill domains and sub-skill descriptions. Using the Delphi methodology, each CTA element was systematically reviewed by a multi-institutional panel of 16 surgical educators and implemented in the final product when content validity index (CVI) reached ≥0.80. In the subsequent validation phase, 3 blinded reviewers independently scored 8 training videos and 39 vesicourethral anastomoses (VUA) using EASE; 10 VUA were also scored using Robotic Anastomosis Competency Evaluation (RACE), a previously validated, but simplified suturing assessment tool. Inter-rater reliability was measured with intra-class correlation (ICC) for normally distributed values and prevalence-adjusted bias-adjusted Kappa (PABAK) for skewed distributions. Expert (≥100 prior robotic cases) and trainee (<100 cases) EASE scores from the non-training cases were compared using a generalized linear mixed model. Results: After two rounds of Delphi process, panelists agreed on 7 domains, 18 sub-skills, and 57 detailed sub-skill descriptions with CVI ≥ 0.80. Inter-rater reliability was moderately high (ICC median: 0.69, range: 0.51-0.97; PABAK: 0.77, 0.62-0.97). Multiple EASE sub-skill scores were able to distinguish surgeon experience. The Spearman's rho correlation between overall EASE and RACE scores was 0.635 (p=0.003). Conclusions: Through a rigorous CTA and Delphi process, we have developed EASE, whose suturing sub-skills can distinguish surgeon experience while maintaining rater reliability.

Development and validation of an objective scoring tool to evaluate surgical dissection: Dissection Assessment for Robotic Technique (DART).

Purpose: Evaluation of surgical competency has important implications for training new surgeons, accreditation, and improving patient outcomes. A method to specifically evaluate dissection performance does not yet exist. This project aimed to design a tool to assess surgical dissection quality. Methods: Delphi method was used to validate structure and content of the dissection evaluation. A multi-institutional and multi-disciplinary panel of 14 expert surgeons systematically evaluated each element of the dissection tool. Ten blinded reviewers evaluated 46 de-identified videos of pelvic lymph node and seminal vesicle dissections during the robot-assisted radical prostatectomy. Inter-rater variability was calculated using prevalence-adjusted and bias-adjusted kappa. The area under the curve from receiver operating characteristic curve was used to assess discrimination power for overall DART scores as well as domains in discriminating trainees (≤100 robotic cases) from experts (>100). Results: Four rounds of Delphi method achieved language and content validity in 27/28 elements. Use of 3- or 5-point scale remained contested; thus, both scales were evaluated during validation. The 3-point scale showed improved kappa for each domain. Experts demonstrated significantly greater total scores on both scales (3-point, p< 0.001; 5-point, p< 0.001). The ability to distinguish experience was equivalent for total score on both scales (3-point AUC= 0.92, CI 0.82-1.00, 5-point AUC= 0.92, CI 0.83-1.00). Conclusions: We present the development and validation of Dissection Assessment for Robotic Technique (DART), an objective and reproducible 3-point surgical assessment to evaluate tissue dissection. DART can effectively differentiate levels of surgeon experience and can be used in multiple surgical steps.

Assessing Cost of Robotic Utilization in Partial Nephrectomy with Increasing Utilization.

PURPOSE: To evaluate trends in utilization of robotic assistance in partial nephrectomy (PN) and assess the association between cost and utilization. PATIENTS AND METHODS: Using the 2009-2012 Nationwide Inpatient Sample database, we identified all adult (>17 years) patients undergoing PN for localized primary renal malignancy. Coding for robotic assistance (17.4 × ) began in the final quarter of 2008. The primary outcome was total hospital cost exclusive of physician fees. A multiple linear regression model was used to adjust for patient and hospital characteristics. RESULTS: Between 2009 and 2012, there were 32,664 (58%) open, 3498 (6%) laparoscopic, and 20,350 (36%) robot-assisted partial nephrectomies performed in the United States. Between 2009 and 2012, the total number of partial nephrectomies semiannually increased by 93% (5114-9845) with robotic partial nephrectomies (RPNs) representing >80% of the increase. RPN increased from 1029 cases in the first half of 2009 to 4840 in the last half of 2012 and surpassed utilization of open nephrectomy. The proportion of all partial nephrectomies performed with robotic assistance increased from 20% to 49% during the same period. After adjusting for demographics, Charlson comorbidity index, and hospital region, RPN went from $1,464 (p = 0.009) more than open in 2009 to $456 (p = 0.28) less than open in 2012. CONCLUSIONS: Utilization of RPN surpassed open in 2012 in the United States. The difference in cost between the robotic and open approaches decreased during the study period and by 2011 was not statistically different.

Crowdsourcing Assessment of Surgeon Dissection of Renal Artery and Vein During Robotic Partial Nephrectomy: A Novel Approach for Quantitative Assessment of Surgical Performance.

INTRODUCTION: We sought to describe a methodology of crowdsourcing for obtaining quantitative performance ratings of surgeons performing renal artery and vein dissection of robotic partial nephrectomy (RPN). We sought to compare assessment of technical performance obtained from the crowdsourcers with that of surgical content experts (CE). Our hypothesis is that the crowd can score performances of renal hilar dissection comparably to surgical CE using the Global Evaluative Assessment of Robotic Skills (GEARS). METHODS: A group of resident and attending robotic surgeons submitted a total of 14 video clips of RPN during hilar dissection. These videos were rated by both crowd and CE for technical skills performance using GEARS. A minimum of 3 CE and 30 Amazon Mechanical Turk crowdworkers evaluated each video with the GEARS scale. RESULTS: Within 13 days, we received ratings of all videos from all CE, and within 11.5 hours, we received 548 GEARS ratings from crowdworkers. Even though CE were exposed to a training module, internal consistency across videos of CE GEARS ratings remained low (ICC = 0.38). Despite this, we found that crowdworker GEARS ratings of videos were highly correlated with CE ratings at both the video level (R = 0.82, p < 0.001) and surgeon level (R = 0.84, p < 0.001). Similarly, crowdworker ratings of the renal artery dissection were highly correlated with expert assessments (R = 0.83, p < 0.001) for the unique surgery-specific assessment question. CONCLUSIONS: We conclude that crowdsourced assessment of qualitative performance ratings may be an alternative and/or adjunct to surgical experts' ratings and would provide a rapid scalable solution to triage technical skills.

Reducing Operating Room Costs Through Real-Time Cost Information Feedback: A Pilot Study.

PURPOSE: To create a protocol for providing real-time operating room (OR) cost feedback to surgeons. We hypothesize that this protocol will reduce costs in a responsible way without sacrificing quality of care. METHODS: All OR costs were obtained and recorded for robot-assisted partial nephrectomy and laparoscopic donor nephrectomy. Before the beginning of this project, costs pertaining to the 20 most recent cases were analyzed. Items were identified from previous cases as modifiable for replacement or omission. Timely feedback of total OR costs and cost of each item used was provided to the surgeon after each case, and costs were analyzed. RESULTS: A cost analysis of the robot-assisted partial nephrectomy before the washout period indicates expenditures of $5243.04 per case. Ten recommended modifiable items were found to have an average per case cost of $1229.33 representing 23.4% of the total cost. A postwashout period cost analysis found the total OR cost decreased by $899.67 (17.2%) because of changes directly related to the modifiable items. Therefore, 73.2% of the possible identified savings was realized. The same stepwise approach was applied to laparoscopic donor nephrectomies. The average total cost per case before the washout period was $3530.05 with $457.54 attributed to modifiable items. After the washout period, modifiable items costs were reduced by $289.73 (8.0%). No complications occurred in the donor nephrectomy cases while one postoperative complication occurred in the partial nephrectomy group. CONCLUSION: Providing surgeons with feedback related to OR costs may lead to a change in surgeon behavior and decreased overall costs. Further studies are needed to show equivalence in patient outcomes.

Changing USA national trends for adrenalectomy: the influence of surgeon and technique.

OBJECTIVE: To explain differences over time between operative approach and surgeon type for adrenal surgery in the USA. PATIENTS AND METHODS: A retrospective cohort analysis was performed on all patients undergoing adrenalectomy between 2002 and 2011 using the Nationwide Inpatient Sample. Patients undergoing concurrent nephrectomy were excluded. Surgeon specialty was only available for 2003-2009. Descriptive analyses and multivariable logistic regression models were used to assess variables associated with minimally invasive surgery (MIS) and urologist-performed procedures. RESULTS: In all, 58,948 adrenalectomies were identified. A MIS approach was used in 20% of these operations. There was a 4% increase in MIS throughout the study period (P < 0.001). Cases performed at teaching hospitals were more likely to be MIS (odds ratio [OR] 1.47, P < 0.001). We were able to identify surgical specialty in 23,746 cases, of which 60% were performed by urologists. Cases performed in the Midwest compared with Northeast were at increased adjusted odds of being performed by urologists (OR 1.38, P = 0.11). Despite most cases being performed by urologists, adrenalectomy by urologists showed a 15% annual decrease over the analysed period (P < 0.001). CONCLUSIONS: The use of a MIS technique to perform adrenalectomy is increasing at a slower rate compared with most other surgical extirpative procedures. Further investigation to explain the decreased performance of adrenalectomy by urologists is warranted.

The impact of hospital volume on postoperative complications following robot-assisted partial nephrectomy.

PURPOSE: We sought to evaluate the relationship between hospital volume and postoperative complications following robot-assisted partial nephrectomy (RAPN) using the Nationwide Inpatient Sample. MATERIALS AND METHODS: We identified patients undergoing RAPN between 2009 and 2011. Hospitals were divided into volume-based tertiles for each year (high, medium, low). Descriptive analyses were performed using Pearson's chi-squared and Student's t-test. Multivariable logistic regression assessed the association between hospital volume and postoperative complications, adjusting for age, gender, hospital region, type of hospital, primary payer, comorbidities, and kidney cancer. RESULTS: We identified 17,583 cases from 323 hospitals, of which 112 were low volume, 112 medium volume, and 99 high volume. 13,645 (78%) cases were performed at high-volume institutions. Eleven percent of patients developed an in-hospital postoperative complication, with 15% at low-volume, 12% at medium-volume, and 10% at high-volume hospitals (p=0.071). In addition, blood transfusion was less common at high-volume hospitals (p=0.015). On multivariable logistic regression, high-volume hospitals had 42% decreased odds of postoperative in-hospital complications (95% confidence interval 0.37-0.90; p=0.016). Complications were associated with a $4500 increase in hospital costs. CONCLUSIONS: High-volume hospitals are associated with decreased blood transfusions and complications. With the recognition that high-volume RAPN hospitals are independently associated with improved clinical outcomes, further studies should be performed to determine the role of the hospital and surgeon volume thresholds in the performance of RAPN.

Does robotic assistance confer an economic benefit during laparoscopic radical nephrectomy?

PURPOSE: While robotic assisted radical nephrectomy is safe with outcomes and complication rates comparable to those of the pure laparoscopic approach, there is little evidence of an economic or clinical benefit. MATERIALS AND METHODS: From the 2009 to 2011 Nationwide Inpatient Sample database we identified patients 18 years old or older who underwent radical nephrectomy for primary renal malignancy. Robotic assisted and laparoscopic techniques were noted. Patients treated with the open technique and those with evidence of metastatic disease were excluded from analysis. Descriptive statistics were performed using the chi-square and Mann-Whitney tests, and the Student t-test. Multiple linear regression was done to examine factors associated with increased hospital costs and charges. RESULTS: We identified 24,312 radical nephrectomy cases for study inclusion, of which 7,787 (32%) were performed robotically. There was no demographic difference between robotic assisted and pure laparoscopic radical nephrectomy cases. Median total charges were $47,036 vs $38,068 for robotic assisted vs laparoscopic surgery (p <0.001). Median total hospital costs for robotic assisted surgery were $15,149 compared to $11,735 for laparoscopic surgery (p <0.001). There was no difference in perioperative complications or the incidence of death. Compared to the laparoscopic approach robotic assistance conferred an estimated $4,565 and $11,267 increase in hospital costs and charges, respectively, when adjusted for adapted Charlson comorbidity index score, perioperative complications and length of stay (p <0.001). CONCLUSIONS: Robotic assisted radical nephrectomy results in increased medical expense without improving patient morbidity. Assuming surgeon proficiency with pure laparoscopy, robotic technology should be reserved primarily for complex surgeries requiring reconstruction. Traditional laparoscopic techniques should continue to be used for routine radical nephrectomy.

Economic and utilization analysis of robot-assisted versus laparoscopic live donor nephrectomy.

BACKGROUND: Reports of robot-assisted live donor nephrectomies (LDNs) have been emerging in the literature. We sought to examine the national incidence of robot-assisted LDNs and to assess regional use and economic differences in robot-assisted versus laparoscopic LDN. METHODS: Data from the Nationwide Inpatient Sample (NIS) were used to identify patients who underwent either laparoscopic or robot-assisted LDN between 2009 and 2011. Descriptive analysis was performed to examine differences between the laparoscopic and robot-assisted groups. RESULTS: A total of 4,163 cases of LDN were performed using robot-assistance or pure laparoscopic surgery between 2009 and 2011. Of these, 142 were classified as robot-assisted nephrectomies; these cases were all from the western United States. There was no difference in the incidence of complications between the laparoscopic and robot-assisted groups (P=0.206). Median (interquartile range [IQR]) total charges for robot-assisted LDN were $48,639 ($42,380-$53,050) vs $37,019 ($28,715-$48,816) for laparoscopic cases (P<0.001). CONCLUSIONS: The role of robotic assistance in LDN remains to be determined; we identified no benefits to robotic assistance in our study.

Trends in robot-assisted laparoscopic pyeloplasty in pediatric patients.

OBJECTIVE: To evaluate the incidence of pediatric robotic-assisted laparoscopic pyeloplasties (RALPs) and to determine if there were regional or age-related trends associated with the performance of RALP. METHODS: Using 2005-2010 data from the Nationwide Inpatient Sample (NIS), the incidence of and trends in pyeloplasty in patients less than 18 years of age were assessed. This was broken down by open, laparoscopic, and robotic techniques when possible. Multiple logistic regression determined which characteristics were associated with increased performance of RALP. Population weighting was used to estimate national rates. RESULTS: A total of 15,498 pediatric pyeloplasties were performed between 2005 and 2010. Coding for robotics began at the end of 2008, and, since then, 750 of the 5557 pediatric pyeloplasties were robotic. The rate of RALP remained unchanged from 2008-2010 (odds ratio [OR] 0.93, P = .051); however, there was an overall increase in minimally invasively procedures (RALP or laparoscopic) since 2005 (OR 1.4, P <.001). Factors associated with increased performance of RALP were aged above 11 years (OR 50.3, P <.001) and living in the northeast (OR 3.0, P = .001), midwest (OR 2.9, P = .001), or west (OR 4.31, P <.001) compared with the south. CONCLUSION: An estimated 750 robotic pyeloplasties were performed in the United States between the end of 2008 and 2010. There was an increase in the total number of pyeloplasties performed using minimally invasive techniques since 2005. Older children are more likely and patients living in the south are less likely to be treated with robotic assistance.

Determination of patient concerns in choosing surgery and preference for laparoendoscopic single-site surgery and assessment of satisfaction with postoperative cosmesis.

UNLABELLED: background and purpose: Laparoendoscopic single-site (LESS) surgery offers potential improvements in cosmesis and recovery over standard laparoscopy (SL). We report the factors with which patients are most concerned in choosing surgery and how these affect preference for LESS. In addition, we rate the satisfaction of scars after laparoscopy. PATIENTS AND METHODS: Patients followed after a laparoscopic procedure completed two surveys. First, patients rated, on a 5-point Likert scale, the importance of pain, recovery time, cost, treatment success, scars, and complications in choosing surgery. In addition, they were asked their preference for LESS. In the second survey, the impact of scars on body image and cosmesis was assessed. RESULTS: Seventy-nine patients (median age 54.8 years, 65% male and 35% female) were treated for malignancy (53), donation (15), and benign indications (9). Treatment success (4.71 ± 0.81) and complications (4.22 ± 1.16) were most important, followed by pain (3.43 ± 1.21) and convalescence (3.65 ± 1.11), P<0.05. Cost was rated 2.68 ± 1.38, and cosmesis was 2.22 ± 1.13 (P<0.005). Cosmesis score increased in females (2.59 ± 1.08 vs 2.02 ± 1.12), patients <50 years (2.59 ± 1.09 vs 2.02 ± 1.12), and benign surgical indication (3.33 ± 1.12 vs 2.07 ± 1.06), P<0.05. LESS was preferred in 30.4%, SL in 39.2%. Concern for cosmesis was associated with LESS preference (48.5% vs 17.8%, P=0.004). Sex, age, and surgical indication also influenced this. On the body image scale, patients scored a mean 18.8 ± 1.5 of 20. Patients rated scar appearance 8.31 ± 1.80 of 10. CONCLUSION: Patients who were treated with laparoscopy were most concerned with success and complication. Preference for LESS was influenced by concerns for cosmesis, sex, age, and surgical indication.

Optical-access visual obturator trocar entry into desufflated abdomen during laparoscopy: assessment after 96 cases.

BACKGROUND: The introduction of optical-access laparoscopic trocars was met with enthusiasm and the impression that these devices provide safer access with decreased complication rates. However, serious complications have been reported. PATIENTS AND METHODS: We retrospectively reviewed our first 96 consecutive cases (17 radical prostatectomies, 2 sacrocolpopexies, 6 adrenalectomies, and 71 renal procedures), performed between October 2001 and April 2003, of optical-access laparoscopic trocar placement as initial entry into the desufflated abdomen. After creating a 12-mm periumbilical or lateral-rectus incision, the 12-mm Endopath Bladeless visual obturator trocar (Ethicon Endosurgery, Cincinnati, OH) was inserted into the peritoneum while carefully observing the separation of the layers of fascia, muscle, and peritoneum. RESULTS: There were no vascular injuries. However, we observed 2 (2.1%) large-bowel injuries: a seromuscular injury and a through-and-through enterotomy of the mid-descending colon. In both cases, the visual obturator was placed lateral to the left rectus muscle, and the large colon was noted to be adherent to the anterior abdominal wall. The bowel injuries were repaired in two layers (running 3-0 Vicryl for the mucosa and 3-0 silk for the seromuscular layer). The operations were completed without open conversion and with uneventful recovery. CONCLUSIONS: Direct placement of an optical-access visual obturator trocar into the desufflated abdomen carries the potential for significant injury. Our current practice is to place the visual trocar after Veress-needle peritoneal insufflation.

Evaluation of synchronous twin pulse technique for shock wave lithotripsy: determination of optimal parameters for in vitro stone fragmentation.

PURPOSE: The Twinheads extracorporeal shock wave lithotriptor (THSWL) is composed of 2 identical shock wave generators and reflectors. One reflector is under the table and the other is over the table with a variable angle between the axes of the 2 reflectors. The 2 reflectors share a common second focal point, making it possible to deliver an almost synchronous twin pulse to the targeted stone. We studied the optimal parameters for in vitro stone fragmentation. MATERIALS AND METHODS: Two types of 1 cm artificial stones were used, namely Bon(n)-stones of 3 compositions (75% calcium oxalate monohydrate [COM] plus 25% uric acid, struvite and cystine) and plaster of Paris. The parameters tested were shock wave number (100, 500 and 1,000), shock wave power (8, 11 and 14 kV) and angle between the reflector axes (67, 90 and 105 degrees). After the optimal parameters were determined we studied the disintegrative efficacy of THSWL for 3 types of human urinary calculi, including COM, calcium hydrogen phosphate (brushite) and cystine. Each stone received 1,000 twin shock waves at 14 kV with an angle of 90 degrees between the reflectors. All experiments were done using a rate of 60 twin shock waves per minute. Following lithotripsy stone fragments were processed and sized. The ratio of the weight of fragments greater than 2 mm-to-total weight of all fragments was calculated. RESULTS: Optimal stone fragmentation results for THSWL were obtained with the maximum number of shock waves (1,000) and full power (14 kV). There was no significant statistical difference in fragment size or the ratio of fragments greater than 2 mm with the use of different angles except for cystine and plaster of Paris calculi, for which the right angle was most effective. At application of the optimal parameters to human stones THSWL produced small fragment size for COM and cystine stones, while brushite stones were not fragmented to the same extent. CONCLUSIONS: The efficacy of synchronous twin pulse technology improves as the number of shock waves and power increase. A 90-degree angle between the shock wave reflectors is advantageous for certain stones (that is cystine and plaster of Paris) but it is not a factor for other stone compositions. THSWL has satisfactory disintegrative efficacy for human stones, especially COM and cysteine calculi.