Systematic review of learning curves in robot-assisted surgery.

BACKGROUND: Increased uptake of robotic surgery has led to interest in learning curves for robot-assisted procedures. Learning curves, however, are often poorly defined. This systematic review was conducted to identify the available evidence investigating surgeon learning curves in robot-assisted surgery. METHODS: MEDLINE, Embase and the Cochrane Library were searched in February 2018, in accordance with PRISMA guidelines, alongside hand searches of key congresses and existing reviews. Eligible articles were those assessing learning curves associated with robot-assisted surgery in patients. RESULTS: Searches identified 2316 records, of which 68 met the eligibility criteria, reporting on 68 unique studies. Of these, 49 assessed learning curves based on patient data across ten surgical specialties. All 49 were observational, largely single-arm (35 of 49, 71 per cent) and included few surgeons. Learning curves exhibited substantial heterogeneity, varying between procedures, studies and metrics. Standards of reporting were generally poor, with only 17 of 49 (35 per cent) quantifying previous experience. Methods used to assess the learning curve were heterogeneous, often lacking statistical validation and using ambiguous terminology. CONCLUSION: Learning curve estimates were subject to considerable uncertainty. Robust evidence was lacking, owing to limitations in study design, frequent reporting gaps and substantial heterogeneity in the methods used to assess learning curves. The opportunity remains for the establishment of optimal quantitative methods for the assessment of learning curves, to inform surgical training programmes and improve patient outcomes.

ANTECEDENTES: La aceptación creciente de la cirugía robótica ha generado interés en las curvas de aprendizaje para los procedimientos asistidos por robot. Sin embargo, las curvas de aprendizaje a menudo están mal definidas. Esta revisión sistemática se realizó para identificar la evidencia disponible en relación a las curvas de aprendizaje del cirujano en la cirugía asistida por robot. MÉTODOS: En Febrero de 2018, se realizaron búsquedas en MEDLINE, Embase y Cochrane Library, de acuerdo con las recomendaciones PRISMA, junto con búsquedas manuales de congresos clave y de revisiones ya existentes. Los artículos elegibles fueron aquellos que evaluaron las curvas de aprendizaje asociadas con la cirugía asistida por robot efectuada en pacientes. RESULTADOS: Las búsquedas bibliográficas identificaron 2.316 registros de los cuales 68 cumplían los criterios de elegibilidad y correspondían a 68 estudios primarios. De estos 68 estudios, 49 evaluaron las curvas de aprendizaje basadas en datos de pacientes de 10 especialidades quirúrgicas. Los 49 estudios eran todos estudios observacionales, en su mayoría de un solo brazo (35/49 (71%)) e incluían pocos cirujanos. Las curvas de aprendizaje mostraban una notable heterogeneidad, variando entre procedimientos, estudios y parámetros analizados. Los estándares de presentación de informes fueron generalmente deficientes, con solo 17/49 (35%) cuantificando la experiencia previa. Los métodos utilizados para evaluar la curva de aprendizaje fueron heterogéneos, a menudo carecían de validación estadística y usaban terminología ambigua. CONCLUSIÓN: Las estimaciones de la curva de aprendizaje estaban sujetas a una considerable incertidumbre, careciendo de evidencia robusta por las limitaciones en el diseño del estudio, lagunas de información en los artículos y heterogeneidad sustancial en los métodos utilizados para evaluar las curvas de aprendizaje. Queda pendiente establecer métodos cuantitativos óptimos para evaluar las curvas de aprendizaje, informar de los programas de formación quirúrgica y mejorar los resultados del paciente.

A critical systematic review of recent clinical trials comparing open retropubic, laparoscopic and robot-assisted laparoscopic radical prostatectomy.

The surgical treatment of prostate cancer has evolved rapidly, driven by technological advances that have made minimally-invasive prostatectomy feasible. The contemporary surgical approaches are laparoscopic radical prostatectomy (LRP) and robot-assisted laparoscopic radical prostatectomy (RALP). These are now considered standard modalities of treatment in urology departments across North America, Europe and centres of excellence world-wide. However, despite the widespread adoption of minimally-invasive approaches there are only a handful of robust studies directly comparing the results of these techniques with the gold standard approach of open radical prostatectomy (ORP). Of note, uncertainty remains over exactly which men with localised prostate cancer will benefit from radical treatment and the reduction of surgical side-effects is paramount in optimising outcomes. This systematic review examines the current status of minimally- invasive prostatectomy focussing on peri-operative, oncological and urogenital functional outcomes.

Enhancement of immune responses to infectious bursal disease vaccine by supplement of an extract made from Momordica cochinchinensis (Lour.) Spreng. seeds.

The immunological effect of an extract from Momordica cochinchinensis seed (ECMS) on immune responses against infectious bursal disease (IBD) in chickens was evaluated. Fifty-two birds were equally divided into 4 groups and immunized with inactivated IBD vaccine alone (controls) or IBD vaccine emulsified with ECMS (20, 40, and 80 microg). Serum IgG antibody levels against IBD and BW were measured on 0, 7, 14, 21, 28, and 35 d after immunization. The ELISA results revealed that the chickens that received 20 microg of ECMS had significantly enhanced antibody levels on 14, 21, 28, and 35 d when compared with controls (P<0.05). A significant increase in mitogenic stimulated lymphocyte proliferation was also recorded in all ECMS groups as compared with controls (P<0.05; P<0.01). No adverse effect of ECMS was noted on growth performance, although average weight gain was significantly higher in 20 microg (7, 14, 21, 28, and 35 d) and 40 or 80 microg (14 d) of ECMS groups as compared with controls (P<0.05; P<0.01). Further studies are suggested for the investigation of immunological effects of ECMS.

Bilateral simultaneous single-port (LESS) laparoscopic nephrectomy (laparoendoscopic single site surgery).

Minimal access surgery is rapidly expanding and currently single-port surgery is at the forefront of laparoscopy. Operating through a single port is technically demanding but through advances in camera design and instrument design, it is now gaining popularity. It offers minimal scar surgery as well as decreased postoperative pain and swift recovery. Here we present a case of bilateral simultaneous single-port laparoscopic nephrectomy (LESS) laparoendoscopic single site surgery in a 51-year-old man. Illustrating that LESS can be used by surgeons with laparoscopic skills outside of a few major international centers.

Laparoscopic renal cooling device.

A new medical device has been designed for inducing hypothermia in kidneys, via laparoscopic deployment, without leaving residual fluid in the abdomen. It was tested in laboratory and animal trials to ascertain its suitability for achieving a target renal temperature of 15 degrees C for tissue preservation within a 30-min period. A simple theoretical model was developed to calculate cooling rates under ideal circumstances. In the laboratory, a potato was used as the model for the kidney and an average minimum temperature of 15.8 degrees C was reached in 30 min. The theoretical model calculated this as 9.9 degrees C. In the animal trials, an average minimum temperature of 11.4 degrees C was reached in 30 min, compared to the calculated temperature of 9.8 degrees C from the theoretical model. In conclusion, the new device can cool as affectively as other techniques trialled, with the added advantage that it does not release cold fluid or ice into the abdomen.

Evaluation of the ischemic protection efficacy of a laparoscopic renal cooling device using renal transplantation viability assessment criteria in a porcine model.

PURPOSE: We assessed the efficacy of a prototype laparoscopic topical cooling device. The aim of regional renal hypothermia in laparoscopic surgery is to limit ischemic injury and extend safe operative time. A reliable model for assessing renal ischemic injury exists in the field of nonheart beating donor renal transplantation. Hypothermic machine perfusion allows calculation of the pressure flow index and measurement of glutathione S-transferase in the perfusate. These parameters allow accurate assessment of the extent of renal damage. MATERIALS AND METHODS: The device incorporates a 2-layer cooling bag and coolant circuit. The system achieves hypothermia by circulating coolant across the surface of the kidney. Using 10 pigs individual kidneys were subjected to periods of renal ischemia with or without device in situ cooling. Each kidney was then machine perfused and assessed using nonheart beating donor viability criteria. RESULTS: The best performance of the device achieved a renal parenchymal temperature of 15C in 11.2 minutes (mean +/- SD 21.4 +/- 8.42). In the warm ischemia groups significant deterioration of pressure flow index compared to controls occurred by 60 minutes (p = 0.0001). In cooled kidneys at 60 minutes the mean pressure flow index was not significantly different from that in controls. Greater mean glutathione S-transferase measurements were associated with the warm ischemia groups. CONCLUSIONS: Our study reinforces the efficacy of topical renal cooling in the laparoscopic setting. We report the use of assessment techniques capable of accurate quantitative measurement of renal injury in an animal model. Our cooling device is currently undergoing further development to enhance its efficiency.

Positive margins in laparoscopic partial nephrectomy in 855 cases: a multi-institutional survey from the United States and Europe.

PURPOSE: Open partial nephrectomy has emerged as the standard of care in the management of renal tumors smaller than 4 cm. While laparoscopic radical nephrectomy has been shown to be comparable to open radical nephrectomy with respect to long-term outcomes, important questions remain unanswered regarding the oncological efficacy of laparoscopic partial nephrectomy. We examined the practice patterns and pathological outcomes following laparoscopic partial nephrectomy. MATERIALS AND METHODS: A survey was sent to academic medical centers in the United States and in Europe performing laparoscopic partial nephrectomy. The total number of laparoscopic partial nephrectomies, positive margins, indications for intraoperative frozen biopsy as well as tumor size and position were queried. RESULTS: Surveys suitable for analysis were received from 17 centers with a total of 855 laparoscopic partial nephrectomy cases. Mean tumor size was 2.7 cm (+/-0.6). There were 21 cases with positive margins on final pathology, giving an overall positive margin rate of 2.4%. Intraoperative frozen sections were performed selectively at 10 centers based on clinical suspicion of positive margins on excised tumor. Random biopsies were routinely performed on the resection bed at 5 centers. Frozen sections were never performed at 2 centers. Of the 21 cases with positive margins 14 underwent immediate radical nephrectomy based on the frozen section and 7 were followed expectantly. CONCLUSIONS: Early experience with laparoscopic partial nephrectomy in this multicenter study demonstrates oncological efficacy comparable to that of open partial nephrectomy with respect to the incidence of positive margins. The practice of intraoperative frozen sections varied among centers and is not definitive in guiding the optimal surgical treatment.

Ischemia-reperfusion injury in cadaveric nonheart beating, cadaveric heart beating and live donor renal transplants.

PURPOSE: Ischemia-reperfusion injury is gaining importance in transplantation as being responsible for allograft dysfunction. Ischemia occurs during kidney procurement, which is shortest in LDs, and prolonged in cadaveric HBDs and NHBDs. MATERIALS AND METHODS: Renal transplants from 17 LDs, 15 HBDs and 19 NHBDs were assessed during reperfusion for biochemical markers of ischemia-reperfusion injury and assessed clinically. Central venous blood sampling was assayed for free radicals using electron spin resonance and tissue injury biomarkers, namely lactate dehydrogenase, fatty acid binding protein, alanine aminopeptidase, lactate and total antioxidants. RESULTS: The return to stable renal function was more rapid in LD renal transplants, while recovery continued from 3 months after hospital discharge in NHBD renal transplants. Injury markers, such as lactate dehydrogenase, fatty acid binding protein, alanine aminopeptidase and lactate, were raised at the time of reperfusion, especially in NHBD renal transplants. Free radical release measured by electron spin resonance showed 2 phase release, that is early (0 to 10-minute) and late (20 to 40-minute) release. In NHBD, HBD and LD renal transplants the index of free radical release in the early phase was 1.43, 1.36 and 1.20, and in the late phase it was 1.43, 1.38 and 0.97, respectively (each ANOVA p <0.05). CONCLUSIONS: NHBD renal transplants were accompanied by a greater release of free radicals at reperfusion (NHBD > HBD > LD), which was associated with an increase in tissue injury markers at reperfusion. This was reflected in a slower return to stable renal function in NHBD compared to HBD and LD renal transplants.

Do recipients of kidneys from donors treated with streptokinase develop anti-streptokinase antibodies?

Streptokinase is used for preflush for non-heart-beating donors (NHBDs) in our center. The aim of this study was to evaluate whether the use of thrombolytic streptokinase results in the production of anti-streptokinase antibodies in the recipients after renal transplantation. Recipient sera taken prior to and at 1 and 6 months posttransplant were tested for the presence of antibodies to streptokinase using an enzyme-linked immunosorbent assay assay. No differences were detected between a group of 18 recipients who had kidneys from thrombolytic-treated NHBDs and a further group of 18 who received NHBD kidneys without such treatment.

Laparoscopic radical nephrectomy in first-trimester pregnancy.

We present a case of a 30-year-old pregnant woman with renal cell carcinoma who underwent successful laparoscopic radical nephrectomy at 11 weeks of gestational age. The remainder of the pregnancy was uncomplicated, and the patient gave birth to a healthy baby boy at term. Although previous cases of successful nephrectomy performed in pregnancy for renal cell carcinoma have been reported, we believe this is the first case in which it has been performed laparoscopically. We suggest that when the expertise is available, laparoscopic nephrectomy is a safe alternative to open surgery, with the additional benefits of minimal access surgery.

Reperfusion injury in renal transplantation: comparison of LD, HBD and NHBD renal transplants.

Comparison of reperfusion injury in kidneys transplanted from LD, HBD or NHBD donors is presented in the paper. Central venous blood samples (taken during perioperative period) was assessed for free radicals, total antioxidant activity and various markers of tissue injury. There was demonstrable ischemia reperfusion injury occurring at the time of revascularization, which was particularly notable in kidneys transplanted from NHBD donors.

Anaesthesia for laparoscopic urological surgery.

Laparoscopy for urological surgery is a relatively recent surgical innovation. Some centres have substantial experience of single operations, but very few have experience with a comprehensive range. Our programme began with nephrectomy and pyeloplasty, and has expanded to provide for a living related kidney donor programme and for other procedures usually conducted open. Recently, it has included prostate and bladder cancer surgery. The learning curve and implications for anaesthesia are described on the basis of the experience of one anaesthetist with 124 patients. Perioperative care issues, in common with other abdominal laparoscopic procedures, relate to operating positions, the consequences of carbon dioxide under pressure in the abdomen and postoperative analgesia. There is only a small requirement for regional anaesthesia supplementation and invasive analgesia. The corporate laparoscopic cholecystectomy experience was used as the foundation for anaesthesia and to delineate specific organ system issues and any interventions. Significant differences were found in the spectrum of the urological patient population and comorbidity, notably renal function or dysfunction, and complications.

Reducing cardiovascular responses to laryngoscopy and tracheal intubation: a comparison of equipotent doses of tramadol, nalbuphine and pethidine, with placebo.

The stress response to tracheal intubation may be obtunded by opioids given with induction of anesthesia. Tramadol is an opioid acting on mu-receptors and the monoaminergic pain modulating systems. This study examined vasomotor responses to tracheal intubation after equipotent doses of tramadol, nalbuphine and pethidine (3.0, 0.3 mg/kg(-1), and 1.5 mg/kg(-1), respectively), and placebo, given prior to induction of anesthesia in 118 healthy patients. Premedication and induction of anesthesia were standardized. Recordings of HR and SAP were made prior and subsequent to induction of anesthesia, and at 1, 3, 5 and 7 minutes after tracheal intubation. Prior to laryngoscopy and intubation, HR increased in all groups (p < or = 01, all comparisons), but least so after nalbuphine, whilst SAP remained unchanged after placebo, tramadol and pethidine, but fell after nalbuphine (p < 0.025). Maximum increases in HR (p < or = 0.005, all comparisons) and SAP (p < or = 0.02, all comparisons) occurred one minute after intubation. Maximum HR after placebo (108 SD 15 bpm), tramadol (107 SD 20 bpm), pethidine (113 SD 16 bpm) and nalbuphine (110 SD 26 bpm) was similar; with placebo HR remained faster than baseline until the seventh minute but had returned to baseline by the fifth minute with the opioids. Maximum SAP with tramadol (151 SD 26 mmHg) was similar to that with placebo (157 SD 20 mmHg), but was greater than after pethidine (136 SD 27 mmHg; p < 0.05) and nalbuphine (135 SD 19 mmHg; p < 0.02). With each test drug SAP returned to baseline by the third minute. It is concluded that, in these doses, 1) tramadol does not attenuate the chronotropic nor the inotropic response to tracheal intubation, and 2) pethidine and nalbuphine reduce only the inotropic response to airway instrumentation.

A crossover randomized trial of transcutaneous electrical nerve stimulation and oxybutynin in patients with detrusor instability.

PURPOSE: Management of idiopathic detrusor instability is difficult in most patients mainly due to the lack of a complete understanding of the pathophysiology. Oxybutynin and transcutaneous electrical nerve stimulation have been used but to our knowledge no direct comparisons have been made. MATERIALS AND METHODS: Patients with frequency, urgency, urge incontinence and proved detrusor instability were studied with urodynamics, quality of life instruments, and frequency and volume charts. Patients were randomized to transcutaneous electrical nerve stimulation or oxybutynin. After 6 weeks of treatment, they were reassessed and after a washout of 2 weeks, they were started on the second arm of treatment and reassessed 6 weeks later. RESULTS: A total of 13 male and 30 female patients were studied. Functional capacity had increased and number of voids daily had decreased significantly compared with before treatment in both arms (p <0.005). There were significant improvements in symptom specific quality of life measures but no changes were found on the global Short Form 36 (SF-36) quality of life questionnaire. The volume to first desire to void and first unstable contraction had increased significantly with oxybutynin but not with transcutaneous electrical nerve stimulation. Of 23 patients 7 were stabilized with treatment, including 2 with oxybutynin only, 2 with either nerve stimulation or oxybutynin and the remaining 3 with only nerve stimulation. Total bladder capacity did not change significantly with either treatment but patients noticed side effects more commonly with oxybutynin. CONCLUSIONS: Both treatments clearly improved subjective parameters. However, only oxybutynin showed significant improvements in objective urodynamic parameters. Transcutaneous electrical nerve stimulation can be used in patients who cannot take oxybutynin. Further studies are needed to show the long-term efficacy and cost analyses of nerve stimulation.

Treatment of hypospadias: an update of current practice.

Hypospadias is a commonly occurring congenital deformity of the urethra in young boys, which is a cause of concern and psychological trauma for the child and his parents. Although there are numerous procedures for correcting hypospadias, the principles of hypospadias surgery are well defined. Adherence to sound surgical practice can yield good results with low complication rates.

A review of 6978 consecutive admissions to the recovery room at a university hospital.

Recovery from anaesthesia is a time of potential danger to the surgical patients. A retrospective audit of all recovery room admissions over a period of 18 months was carried out at the Aga Khan University Hospital. During this period 6978 patients were admitted to the recovery area and 695 had one or more complications. The complications were recorded by the recovery room nursing staff in a recovery log book. The breakdown of complications according to different physiological systems is discussed. Several surveys have reviewed complications in the western population, but in contrast, no study is available in Pakistani patients. It is recommended that since one in ten patients is likely to have a problem in the early post-operative period, the local hospitals should provide adequate facilities meeting the criteria laid down for the recovery rooms in modern anaesthetic practice.