Assessment of Advanced Perioperative Outcomes to Identify the True Learning Curve of Robotic-assisted Partial Nephrectomy.

OBJECTIVES: To evaluate the learning curve of robotic-assisted partial nephrectomy as it pertains to operative time (OT) and advanced perioperative variables such as achievement of trifecta, postoperative complications, 30-day readmission rates (RR), warm ischemia time (WIT), and functional volume loss (FVL). METHODS: We evaluated 418 consecutive robotic-assisted partial nephrectomy performed by a single surgeon between February 2008 and April 2019. Multivariable log-log regression models were used to evaluate the associations between case number and continuous outcomes (OT, WIT, and FVL). Multivariable logistic regression models were used to evaluate the association of case number with dichotomous outcomes (trifecta, postoperative complications, RR). RESULTS: Among the 406 eligible patients included in the study, 252 (62.1%) were male, median age was 63 years (range, 22-84), and median body mass index was 29 kg/m2 (interquartile range 26-33). Surgeon experience was associated with shorter OT (-2.5% per 50% increase in case number; 95% confidence interval; P <.001) and plateaus around 77 cases performed. There was slight improvement with trifecta (odds ratio [per 50% increase in cases] = 1.08; 95% confidence interval) and the plateau was also at 77 cases, however, this was not statistically significant (P = .086). We did not find statistically significant associations of surgeon experience with FVL (P = .77), postoperative complications (P = .74), WIT (P = .73), or 30-day RR (P = .33). CONCLUSION: There does not appear to be a relationship between surgical experience and grade 3 or higher postoperative complications, 30-day RR, WIT, or FVL. Trifecta outcomes and maximum OT performance appear to be optimized at approximately 77 cases.

Assessment of Perioperative Variables That Predict the Need for Surgical Drains Following Robotic Partial Nephrectomy Utilizing Quantitative Drain Creatinine Analysis.

OBJECTIVE: To utilize body fluid creatinine analysis to determine which patients will require a surgical drain following robotic-assisted partial nephrectomy (RAPN). MATERIALS AND METHODS: One hundred fifty consecutive RAPN performed by a single surgeon were reviewed. Postoperative day (POD) 1 drain creatinine was compared to serum creatinine to calculate the drain to serum creatinine ratio (D/S ratio). Elevated D/S ratio was defined as any value >1.2. RESULTS: From February 2008 to April 2015, 140 patients underwent RAPN and had a drain placed (124 had D/S ratio available on POD 1). In the 103 patients with a D/S ratio of <1.2 and the 21 with D/S ratio of >1.2, the mean tumor size was 3.0 and 3.9 cm (P = .001) and mean RENAL score was 7.6 and 8.1 (P = .270), respectively. Collecting system entry occurred in 68.2% of patients with a D/S ratio of <1.2 and 71.4% of patients with a D/S ratio of >1.2. Mean drain time was 2.4 and 4.2 days (P = .001), hospital stay was 2.7 and 3.3 days (P = .036) for the D/S ratio <1.2 and D/S ratio >1.2 groups, respectively. Those with renal mass size of 4-7 cm had increased likelihood of D/S ratio >1.2 (OR 2.78; P = .041). CONCLUSIONS: Most RAPN do not require a surgical drain. A POD 1 elevated D/S ratio is more likely to occur with larger masses (those approaching or greater than 4 cm) and can be associated with prolonged drain time and hospital stay.

Impact of fellowship training on robotic-assisted laparoscopic partial nephrectomy: benchmarking perioperative safety and outcomes.

To provide perioperative benchmark data for surgeons entering practice from formal robotic training and performing robotic-assisted laparoscopic partial nephrectomy (RAPN). Perioperative outcomes of the first 100 RAPN from a surgeon entering into practice directly from robotic fellowship training were analyzed. Postoperative complications were categorized by Clavien-Dindo grade. Surgical "trifecta scores" and Margin, Ischemia, and Complication (MIC) scoring were utilized to assess surgical outcomes. Statistical analyses were performed using SAS (version 9.2; SAS Institute, Inc., Cary, North Carolina). Median age of the cohort was 63 years (22-81 years), and 34 (34.3%) patients were over age 65. Forty-one (41.4%) patients had a BMI > 30. Thirteen (13.1%) had RENAL 10-12 tumors, 22 of which (22.2%) were >4 cm in size. Median warm ischemia time was 17 min, and 13 patients had resection without warm ischemia. Five patients were converted to open partial nephrectomy, and 1 patient was converted to laparoscopic nephrectomy. Twenty-one patients (21.2%) experienced a complication, 6 of whom had a major (Clavien grade 3 or higher) complication with one grade 5 complication. Operating room time decreased with experience, but surgical complications and hospital stay did not change with experience. MIC score of renal cell carcinoma (RCC) patients was 74.7%, while the surgical trifecta was reached in 71.3 % of RCC patients. Surgeons may enter practice directly from formal robotic training and perform RAPN with perioperative outcomes, surgical complications, surgical trifecta scores, and MIC scoring in line with those the most experienced robotic partial nephrectomists.

Robotic-assisted Bladder Diverticulectomy: Assessment of Outcomes and Modifications of Technique.

OBJECTIVE: To present outcomes of robotic-assisted bladder diverticulectomy (RABD) and technique modifications that may improve outcomes. METHODS: Sixteen consecutive RABDs were performed at our institution by 2 experienced robotic surgeons. Charts were reviewed for patient characteristics, perioperative data, and long-term functional outcomes. Eleven patients (69%) underwent RABD using an external dissection approach, whereas 5 patients (31%) underwent RABD using a modified internal dissection technique (immediate entry into the bladder diverticulum). RESULTS: The mean age of our cohort was 68 years (range, 59-79 years), and 15 of 16 patients (93.8%) were men. Two patients (12.5%) had known malignancy in the diverticulum. Eleven patients (69%) underwent a preoperative outlet procedure (9 transurethral resection of prostate and 2 transurethral incision of prostate) at a median time before RABD of 163.5 days (range, 26-622 days). Median operative time for external RABD was 228 minutes (range, 144-353 minutes) compared with that of 149 minutes (range, 130-189 minutes) for the internal dissection technique. No patient required blood transfusions, and there were no 30-day Clavien grade 3 or 4 complications. Median hospital stay was 2 days (range, 1-3 days). Median postvoid residual before intervention was 458 mL (range, 78-1100 mL) compared with that of 214 mL (range, 46-527 mL) after RABD. Mean American Urological Association symptom score was 18 (range, 5-29) preoperatively compared with that of 7 (range, 2-21) postoperatively. CONCLUSION: RABD is safe with a low risk of intraoperative or postoperative complications and results in both improved voiding symptoms and diminished postvoid residuals. Modifications of technique from an external dissection approach to an internal dissection approach has led to a dramatic reduction in operative time.

Assessment of virtual reality robotic simulation performance by urology resident trainees.

OBJECTIVES: To examine resident performance on the Mimic dV-Trainer (MdVT; Mimic Technologies, Inc., Seattle, WA) for correlation with resident trainee level (postgraduate year [PGY]), console experience (CE), and simulator exposure in their training program to assess for internal bias with the simulator. DESIGN: Residents from programs of the Southeastern Section of the American Urologic Association participated. Each resident was scored on 4 simulator tasks (peg board, camera targeting, energy dissection [ED], and needle targeting) with 3 different outcomes (final score, economy of motion score, and time to complete exercise) measured for each task. These scores were evaluated for association with PGY, CE, and simulator exposure. SETTING: Robotic skills training laboratory. PARTICIPANTS: A total of 27 residents from 14 programs of the Southeastern Section of the American Urologic Association participated. RESULTS: Time to complete the ED exercise was significantly shorter for residents who had logged live robotic console compared with those who had not (p = 0.003). There were no other associations with live robotic console time that approached significance (all p ≥ 0.21). The only measure that was significantly associated with PGY was time to complete ED exercise (p = 0.009). No associations with previous utilization of a robotic simulator in the resident's home training program were statistically significant. CONCLUSIONS: The ED exercise on the MdVT is most associated with CE and PGY compared with other exercises. Exposure of trainees to the MdVT in training programs does not appear to alter performance scores compared with trainees who do not have the simulator.

Assessment of robotic simulation by trainees in residency programs of the Southeastern Section of the American Urologic Association.

OBJECTIVES: To assess the Southeast Section of the American Urological Association (SESAUA) trainee exposure to and thoughts on robotic simulation. DESIGN: Questionnaire-based study of SESAUA residency trainees to determine their access to robotic simulation, live robotic experience to date, and opinion regarding the adequacy of current robotic training. SETTING: Three trainees from each SESAUA training program were invited to Orlando, Florida for a formal 2-day robotic training course. Day 1 was a 3-component didactic session. Day 2 involved faculty directing the trainees in set tasks on a live porcine model for 4 hours and another 4 hours on the Mimic dV-Trainer (Mimic Technologies, Inc, Seattle, WA) for directed exercises. PARTICIPANTS: Thirty-two trainees from 14 programs in the SESAUA participated in the course and filled out a 1-page, 8-item questionnaire following their simulator exposure. RESULTS: Seventeen (53.1%) trainees, including 5 urology year-3 trainees, reported never having had robotic console time. Of the trainees, 65.6% (21 of 32) had access to the Mimic dV-Trainer or Mimic "backpack" whereas 10 had no exposure to robotic simulation; 84.4% (27 of 32) felt that the simulator replicated real-life robotic console surgery and 90.6% (29 of 32) felt the simulator was helpful or would be helpful for training in their program. Trainees felt the "tubes 2" drill, which mimics a vesicourethral anastomosis, was the most difficult drill to perform. CONCLUSIONS: A majority of trainees in the SESAUA have had limited to no robotic console time. A high number of resident trainees in the SESAUA have exposure to virtual reality robotic simulation. Trainees believe that the simulator replicates real-life robotic console movements and almost all believe they would be benefit from having access to robotic simulation.

Cost analysis of open radical cystectomy versus robot-assisted radical cystectomy.

Bladder cancer is the fourth and ninth most common malignancy in males and females, respectively, in the U.S. and one of the most costly cancers to manage. With the current economic condition, physicians will need to become more aware of cost-effective therapies for the treatment of various malignancies. Robot-assisted radical cystectomy (RARC) is the latest minimally invasive surgical option for muscle-invasive bladder cancer. Current reports have shown less blood loss, a shorter hospital stay, and a lower morbidity with RARC, as compared with the traditional open radical cystectomy (ORC), although long-term oncologic results of RARC are still maturing. There are few studies that have assessed the cost outcomes of RARC as compared with ORC. Currently, ORC appears to offer a direct cost advantage due to the high purchase and maintenance cost of the robotic platform, although when the indirect costs of complications and extended hospital stay with ORC are considered, RARC may be less expensive than the traditional open procedure. In order to accurately evaluate the cost effectiveness of RARC versus ORC, prospective randomized trials between the two surgical techniques with long-term oncologic efficacy are needed.

Impact of fellowship training on one-year outcomes of robotic-assisted prostatectomy.

BACKGROUND AND OBJECTIVES: We examined 1-year functional and oncologic outcomes for robotic-assisted laparoscopic prostatectomy (RALP) from a single surgeon entering practice directly from fellowship training. METHODS: We prospectively analyzed the first 100 RALPs performed by one fellowship-trained robotic surgeon. Data included resident involvement during the procedure, perioperative data, and surgical complications (scored using the Clavien grading system). Health-related quality of life (HRQOL) data were captured using the EPIC questionnaire at baseline (prior to surgery) and at 1-year follow-up. RESULTS: Eighty-two patients (82%) had hospital stays of 2 days or less without any postoperative complications, urethral catheter removal was within 14 days of surgery, and none required readmission to the hospital. The overall positive margin rate was 21% (19% for patients with T2 disease). Clavien grades 1 through 4 complication rates, respectively, were 4%, 10%, 1%, and 1%. There were no deaths, reoperations, or bladder neck contractures. One patient (1%) required a blood transfusion within the 90-day perioperative period. At 1-year follow-up, 78% of patients reported wearing no pads; 41.3% of patients with baseline and 1-year follow-up data reported having intercourse. CONCLUSIONS: We provide baseline data pertaining to the morbidity, oncologic efficacy, continence results, and potency outcomes of new surgeons performing RALP.

Safety and peri-operative outcomes during learning curve of robot-assisted laparoscopic prostatectomy: a multi-institutional study of fellowship-trained robotic surgeons versus experienced open radical prostatectomy surgeons incorporating robot-assisted laparoscopic prostatectomy.

PURPOSE: To analyze and compare the safety and peri-operative outcomes of fellowship-trained robotic surgeons (FEL) and experienced open surgeons (OE) incorporating robot-assisted laparoscopic prostatectomy (RALP) into practice. MATERIALS AND METHODS: Multiinstitutional, prospective data were collected on the first 30 RALP performed by FEL and OE (defined as over 1000 prostatectomies) incorporating RALP into practice. Morbidity from the peri-operative course was evaluated as were operative outcomes. The second 30 cases from the OE group were evaluated to assess for improvement with experience. RESULTS: There were no rectal injuries or death in either group. Blood transfusion rates did not differ between the two groups (2% vs. 3%, p = 0.65). Open conversion occurred three times in the OE group but only within the first 30 cases. In the first 30 cases FEL had statistically lower rates of positive margins (15% vs. 34%, p = 0.008) and decreased likelihood of prolonged urethral catheter leakage (5% vs. 19%, p = 0.009). The FEL group had lower rates of failure of prostate-specific antigen to nadir < 0.15 ng/mL (2% vs. 10%, p = 0.056). There were no reoperations in the FEL group but present in 2% of the OE group initially. The second 30 cases of the OE group noted a statistical improvement for all parameters with margin rates and the requirement of prolonged catheterization becoming statistically comparable to those of the FEL group. CONCLUSIONS: OE can safely incorporate RALP into practice and achieve outcomes comparable to FEL quickly. As anticipated, FEL achieve these endpoints earlier in their practice.

Prospective evaluation of factors affecting operating time in a residency/fellowship training program incorporating robot-assisted laparoscopic prostatectomy.

BACKGROUND AND PURPOSE: A current dilemma is how to incorporate robot assisted laparoscopic radical prostatectomy (RALP) into residency/fellowship programs while containing costs and maintaining acceptable operative times. We prospectively analyzed factors that affect the time of nine separate RALP steps performed in a residency/fellowship training program incorporating the da Vinci robot. MATERIALS AND METHODS: A prospective evaluation of 50 consecutive RALP performed by a single surgeon while incorporating trainees was completed. RALP was divided into nine segments, and time of each segment was recorded in minutes. Who performed each portion of the procedure (resident, fellow, or attending surgeon) was also analyzed. The effects of clinical and prostate cancer characteristics were analyzed statistically to investigate associations with procedure completion times for each of the nine segments. Outcomes, including complications and urinary continence, were recorded. RESULTS: Mean age was 58 years, and body mass index was 30 kg/m(2). Mean prostate size was 49.2 grams. Nine patients (18%) had pathologic T(3) disease, and 10 patients (20%) had positive surgical margins. Median total operative time was 276 minutes (range 245-330 min). There was no statistical association with any clinical parameter prolonging total operative time or those of the nine individual steps of the operation. Locally weighted smooth time plots demonstrate stable decreases in all segments with experience. The slowest decreases were seen in bladder neck and neurovascular bundle times. Anastomosis time fluctuated the most. CONCLUSION: RALP can be incorporated successfully into a residency/fellowship training program with acceptable operative times and outcomes even while the supervising physician is on his "learning curve."

Vardenafil rescue rates of sildenafil nonresponders: objective assessment of 327 patients with erectile dysfunction.

OBJECTIVES: To prospectively investigate whether vardenafil can effectively treat patients for whom sildenafil (100 mg) has failed. The introduction of two new oral phosphodiesterase type 5 inhibitors (tadalafil and vardenafil) raises the question of whether the new agents will permit us to treat sildenafil nonresponders with another oral agent. METHODS: Patients were seen at one institution during a 5-year period. A total of 327 patients complaining of sildenafil-refractory erectile dysfunction underwent intracavernous pharmacologic injection and color duplex Doppler ultrasonography. Subsequently 59 of these men tried vardenafil home dosing. RESULTS: Of the 327 men in whom sildenafil failed, 16% were younger than 50, 21% were 51 to 60, 34% were 61 to 70, and 28% were older than 70 years. The Doppler diagnoses were arterial insufficiency in 154 (47%), mixed vascular insufficiency in 73 (22%), and cavernous venous occlusive disease in 57 (17%). Forty-three men (13%) had normal erectile responses to prostaglandin E1 (10 to 20 microg). Of the 59 men who tried vardenafil, 19% were younger than 50, 17% were 51 to 60, 40% were 61 to 70, and 23% were older than 70 years. The Doppler diagnoses were arterial insufficiency in 28 (42%), mixed vascular insufficiency in 10 (19%), and cavernous venous occlusive disease in 15 (29%). Six men (8%) had normal erectile responses to prostaglandin E1. Only 7 (12%) of the 59 men reported that home vardenafil dosing resulted in successful intercourse. CONCLUSIONS: An appropriate diagnostic evaluation and subsequent treatment algorithm have yet to be established for those for whom phosphodiesterase type 5 inhibitors fail. We found that most sildenafil nonresponders had severe arterial insufficiency and were older, with 62% older than 60 years. Our preliminary experience suggests that only a small percentage (12%) of sildenafil nonresponders can be salvaged with vardenafil.