ABSTRACT
OBJECTIVES: Radical cystectomy (RC) is one of the most complex and morbid surgical procedures in Urology. Several retrospective and prospective studies have demonstrated that robotic-assisted RC (RARC) represents a minimally invasive alternative to open surgery, showing non-inferiority in mid-term oncological outcomes. Moreover, important advantages related with perioperative complications have also been published. The aim of this article is to describe RARC surgical steps and to review the most relevant ndings in the eld of RARC, focusing on its strengths and weaknesses when compared with open RC. METHODS: We performed a detailed step-by-step description of the RARC surgical technique, paying particular attention to its specific surgical details and adding our tips and tricks for an out standing performance. We also conducted a review of the most relevant articles in literature in terms of oncological, pathological and perioperative results. All these findings have been compared with the classical open radical cystectomy (ORC) technique. RESULTS: None of the studies published have demonstrated RARC to have worse oncological outcomes (PSM,RFS, CSS, OS) compared to ORC. RARC shows a decrease in blood loss and transfusion rates. No differences have been observed in complications rate, length of hospital stay, quality of life, and time to bowel movement between both approaches. The two disadvantages of RARC compared to ORC are a longer operative time and increased cost. Operating time can be reduced with surgeons gaining experience and technique standardization. The cost disparities and operative time between ORC and RARC at high-volume academic centers are less pronounced than in the general medical community. CONCLUSIONS: RARC is a technically feasible and safe approach, with oncological, pathological and perioperative results, at least, equivalent to ORC.
ARTICULO SOLO EN INGLES.OBJETIVO: La cistectomía radical (CR) esuno de los procedimientos quirúrgicos más complejosy con mayor morbilidad. Varios estudios retrospectivosy prospectivos han demostrado que la CR asistida porrobot (CRAR) representa una alternativa mínimamente invasivaa la cirugía abierta, mostrando no inferioridad enlos resultados oncológicos a medio plazo. Además, sehan publicado importantes ventajas en relación con lascomplicaciones peroperatorias. El objetivo de este artículoes describir los pasos quirúrgicos de la CRAR y revisarlos hallazgos más relevantes en el campo de la CRAR,focalizando en sus fortalezas y debilidades cuando secomparan con la CR abierta. MÉTODOS: Realizamos una descripción paso a paso,detallada, de la técnica quirúrgica de CRAR, poniendoparticular atención a sus detalles quirúrgicos específicos yañadiendo nuestros trucos y consejos para una ejecución excelente. También realizamos una revisión de los artículos más relevantes de la literatura en términos de resultadosoncológicos, patológicos y peroperatorios. Todosestos hallazgos se han comparado con los de la técnicaclásica de cistectomía radical abierta (CRA). RESULTADOS: Ninguno de los estudios publicados hademostrado que la CRAR tenga peores resultados oncológicos(márgenes quirúrgicos positivos, supervivencia librede recurrencia, cáncer específica y global) en comparación con la CRA. La CRAR muestra un descenso del sangradoy las tasas de transfusión. No se han observadodiferencias entre ambos abordajes en las tasas de complicaciones,estancias hospitalarias, calidad de vida y eltiempo hasta la deposición. Dos desventajas de la CRARen comparación con la CRA son el tiempo operatoriomás largo y el aumento del coste. El tiempo operatorio puede reducirse con el aumento de la experiencia de loscirujanos y la estandarización de la técnica. Las disparidadesen los costes y la duración de la cirugía son menospronunciadas en centros académicos de gran volumen que en los de la comunidad médica general. CONCLUSIONES: La CRAR es un abordaje técnicamentefactible y seguro, con resultados oncológicos, patológicosy peroperatorios, al menos, equivalentes a los dela CRA.
Subject(s)
Cystectomy , Robotic Surgical Procedures , Urinary Bladder Neoplasms , Blood Loss, Surgical , Cystectomy/methods , Humans , Postoperative Complications , Prospective Studies , Quality of Life , Retrospective Studies , Treatment Outcome , Urinary Bladder Neoplasms/surgeryABSTRACT
BACKGROUND: The European School of Urology (ESU) started the European Urology Residents Education Programme (EUREP) in 2003 for final year urology residents, with hands-on training (HOT) added later in 2007. OBJECTIVE: To assess the geographical reach of EUREP, trainee demographics, and individual quality feedback in relation to annual methodology improvements in HOT. DESIGN, SETTING, AND PARTICIPANTS: From September 2014 to October 2017 (four EUREP courses) several new features have been applied to the HOT format of the EUREP course: 1:1 training sessions (2015), fixed 60-min time slots (2016), and standardised teaching methodology (2017). The resulting EUREP HOT format was verified by collecting and prospectively analysing the following data: total number of participants attending different HOT courses; participants' age; country of origin; and feedback obtained annually. RESULTS AND LIMITATIONS: A total of 796 participants from 54 countries participated in 1450 HOT sessions over the last 4 yr. This included 294 (20%) ureteroscopy (URS) sessions, 237 (16.5%) transurethral resection (TUR) sessions, 840 (58%) basic laparoscopic sessions, and 79 (5.5%) intermediate laparoscopic sessions. While 712 residents (89%) were from Europe, 84 (11%) were from non-European nations. Of the European residents, most came from Italy (16%), Germany (15%), Spain (15%), and Romania (8%). Feedback for the basic laparoscopic session showed a constant improvement in scores over the last 4 yr, with the highest scores achieved last year. This included feedback on improvements in tutor rating (p=0.017), organisation (p<0.001), and personal experience with EUREP (p<0.001). Limitations lie in the difficulties associated with the use of an advanced training curriculum with wet laboratory or cadaveric courses in this format, although these could be performed in other training centres in conjunction with EUREP. CONCLUSIONS: The EUREP trainee demographics show that the purpose of the course is being achieved, with excellent feedback reported. While European trainees dominate the demographics, participation from a number of non-European countries suggests continued ESU collaboration with other national societies and wider dissemination of simulation training worldwide. PATIENT SUMMARY: In this paper we look at methodological improvements and feedback for the European Urology Residents Education Programme hands-on-training over the last 4 yr.