Comparison of surgical procedures for benign prostatic hyperplasia of medium-volume prostates: evaluation of the causes of rehospitalization from the French National Hospital Database (PMSI-MCO).

PURPOSE: In France, transurethral resection of the prostate (TURP) is still the most commonly used surgical treatment for medium sized benign prostatic hyperplasia (BPH), but the Holmium Laser Enucleation of the Prostate (HoLEP) and laser vaporization procedures are becoming more common. For these three surgical procedures, we evaluate the initial complications, the short term (3 months) and the 4-12-month postoperative complications necessitating re-hospitalization. METHODS: From the French national hospital data base (PMSI-MCO), all hospitalizations for BPH treatment in 2018 were extracted. We document the complications during the initial hospitalization and any subsequent rehospitalizations during the one-year postoperative period. RESULTS: In 2018, 67,220 patients were treated for BPH: 46,242 TURP, 13,509 HoLEP and 7469 laser vaporization. Age and anticoagulation medications were similar for men treated by the three procedures, but TURP patients were more often hypertensive. Infections and hemorrhagic complications were the most common complications at the initial hospitalization: 17%, 10%, 13% for infections and 15%, 8.1%, 11% for hemorrhagic complications respectively, and TURP performed worse than the other two procedures at the initial hospitalization. During the first three months and then the subsequent nine months, there were fewer complications than initially, with little difference between the three procedures, all differences being less than 1%. CONCLUSION: Laser vaporization techniques led to fewer complications. However, the PMSI-MCO only registers complications during hospitalizations. This study should be extended to non-hospitalized, more minor complications.

Robot-assisted vesicovaginal fistula repair: comparison of the extravesical and transvesical techniques.

INTRODUCTION AND OBJECTIVES: Almost two decades after the description of robotic vesicovaginal fistula repair (R-VVF), the literature remains limited. The aims of this study are to report the outcomes of R-VVF and to compare the transvesical versus extravesical techniques. METHODS: We performed an observational, retrospective, multicenter study, including all patients who underwent R-VVF from March 2017 to September 2021 at four academic institutions. All abdominal VVF repair over the study period were performed using a robotic approach. The success of R-VVF was defined as the absence of clinical recurrence. The outcomes of the extravesical versus transvesical techniques were compared. RESULTS: Twenty-two patients were included. The median age was 43 years old (IQR 38-50). Fistulas were supratrigonal and trigonal in 18 and 4 cases respectively. Five patients had undergone previous attempts of fistula repair (22.7%). The fistulous tract was systematically excised, and an interposition flap was used in all but two cases (90.9%). The transvesical and extravesical techniques were used in 13 and 9 cases respectively. There were four postoperative complications, three minor and one major. None of the patients had vesicovaginal fistula recurrence after a median follow-up of 15 months. CONCLUSIONS: The present series, one of the largest R-VVF reported to date, is consistent with the few series already published with a 100% cure rate. Systematic excision of the fistulous tract and the high rate of flap interposition may explain the high success rate. The transvesical and extravesical approaches yielded similar outcomes.

Complications after partial nephrectomy: robotics overcomes open surgery and laparoscopy: the PMSI French national database.

PURPOSE: To evaluate three partial nephrectomies (PN) procedures: open (OPN), standard laparoscopy (LPN), and robot-assisted laparoscopy (RAPN), for the risk of initial complications and rehospitalization for two years after the surgery. MATERIALS AND METHODS: From the French national hospital database (PMSI-MCO), every hospitalization in French hospitals for renal tumor PN in 2016-2017 were extracted. Complications were documented from the initial hospitalization and any rehospitalization over two years. Chi-square and ANOVA tests compared the frequency of complications and length of initial hospitalization between the three surgical procedures. Relative risks (RR) and 95% confidence intervals were computed. RESULTS: The 9119 initial hospitalizations included 4035 OPN, 1709 LPN, and 1900 RAPN; 1475 were excluded as the laparoscopic procedure performed was not determined. The average length of hospitalization was 8.1, 6.2, and 4.5 days for OPN, LPN, and RAPN, respectively. Compared to OPN, there were fewer complications at the time of initial hospitalization for the mini-invasive procedures: 29% for OPN vs. 20% for LPN (0.70 [0.63;0.78]) and 12% for RAPN (RR=0.43, 95%CI [0.38;0.49]). For RAPN compared to LPN, there were fewer haemorrhages (RR=0.55 [0.43;0.72]), anemia (0.69 {0.48;0.98]), and sepsis (0.51 [0.36;0.71]); during follow up, there were fewer urinary tract infections (0.64 [0.45;0.91]) but more infectious lung diseases (1.69 [1.03;2.76]). Over the two-year postoperative period, RAPN was associated with fewer acute renal failures (RR=0.73 [0.55;0.98]), renal abscesses (0.41 [0.23;0.74]), parietal complications (0.69 [0.52;0.92]) and urinary tract infections (0.54 [0.40;0.73]) than for OPN. CONCLUSIONS: Conservative renal surgery is associated with postoperative morbidity related to the surgical procedure fashion. Mini-invasive procedures, especially robot-assisted surgery, had fewer complications and shorter hospital lengths of stay.

Evaluation and understanding of automated urinary stone recognition methods.

OBJECTIVE: To assess the potential of automated machine-learning methods for recognizing urinary stones in endoscopy. MATERIALS AND METHODS: Surface and section images of 123 urinary calculi (109 ex vivo and 14 in vivo stones) were acquired using ureteroscopes. The stones were more than 85% 'pure'. Six classes of urolithiasis were represented: Groups I (calcium oxalate monohydrate, whewellite), II (calcium oxalate dihydrate, weddellite), III (uric acid), IV (brushite and struvite stones), and V (cystine). The automated stone recognition methods that were developed for this study followed two types of approach: shallow classification methods and deep-learning-based methods. Their sensitivity, specificity and positive predictive value (PPV) were evaluated by simultaneously using stone surface and section images to classify them into one of the main morphological groups (subgroups were not considered in this study). RESULTS: Using shallow methods (based on texture and colour criteria), relatively high sensitivity, specificity and PPV for the six classes were attained: 91%, 90% and 89%, respectively, for whewellite; 99%, 98% and 99% for weddellite; 88%, 89% and 88% for uric acid; 91%, 89% and 90% for struvite; 99%, 99% and 99% for cystine; and 94%, 98% and 99% for brushite. Using deep-learning methods, the sensitivity, specificity and PPV for each of the classes were as follows: 99%, 98% and 97% for whewellite; 98%, 98% and 98% for weddellite; 97%, 98% and 98% for uric acid; 97%, 97% and 96% for struvite; 99%, 99% and 99% for cystine; and 94%, 97% and 98% for brushite. CONCLUSION: Endoscopic stone recognition is challenging, and few urologists have sufficient expertise to achieve a diagnosis performance comparable to morpho-constitutional analysis. This work is a proof of concept that artificial intelligence could be a solution, with promising results achieved for pure stones. Further studies on a larger panel of stones (pure and mixed) are needed to further develop these methods.

Sunitinib Alone or after Nephrectomy in Metastatic Renal-Cell Carcinoma.

BACKGROUND: Cytoreductive nephrectomy has been the standard of care in metastatic renal-cell carcinoma for 20 years, supported by randomized trials and large, retrospective studies. However, the efficacy of targeted therapies has challenged this standard. We assessed the role of nephrectomy in patients with metastatic renal-cell carcinoma who were receiving targeted therapies. METHODS: In this phase 3 trial, we randomly assigned, in a 1:1 ratio, patients with confirmed metastatic clear-cell renal-cell carcinoma at presentation who were suitable candidates for nephrectomy to undergo nephrectomy and then receive sunitinib (standard therapy) or to receive sunitinib alone. Randomization was stratified according to prognostic risk (intermediate or poor) in the Memorial Sloan Kettering Cancer Center prognostic model. Patients received sunitinib at a dose of 50 mg daily in cycles of 28 days on and 14 days off every 6 weeks. The primary end point was overall survival. RESULTS: A total of 450 patients were enrolled from September 2009 to September 2017. At this planned interim analysis, the median follow-up was 50.9 months, with 326 deaths observed. The results in the sunitinib-alone group were noninferior to those in the nephrectomy-sunitinib group with regard to overall survival (stratified hazard ratio for death, 0.89; 95% confidence interval, 0.71 to 1.10; upper boundary of the 95% confidence interval for noninferiority, ≤1.20). The median overall survival was 18.4 months in the sunitinib-alone group and 13.9 months in the nephrectomy-sunitinib group. No significant differences in response rate or progression-free survival were observed. Adverse events were as anticipated in each group. CONCLUSIONS: Sunitinib alone was not inferior to nephrectomy followed by sunitinib in patients with metastatic renal-cell carcinoma who were classified as having intermediate-risk or poor-risk disease. (Funded by Assistance Publique-Hôpitaux de Paris and others; CARMENA ClinicalTrials.gov number, NCT00930033 .).

Non-technical skills in robotic surgery and impact on near-miss events: a multi-center study.

BACKGROUND: Robotic surgery requires a set of non-technical skills (NTS), because of the complex environment. We aim to study relationship between NTS and near-miss events in robotic surgery. METHODS: This is an observational study in five French centers. Three robotic procedures were observed and filmed by one of expert trainers in NTS. They established and scored a non-technical skills in robotic surgery (NTSRS) score, that included eight items, each scored from 1 to 5, to assess the whole surgical teams. The surgical teams also self-assessed their work. The number of near-miss events was recorded and classified as minor, or major but no harm incidents, independently by two surgeons. Correlations were Spearman coefficients. RESULTS: Of the 26 procedures included, 15 were prostatectomy (58%), 9 nephrectomy (35%), and 2 pyeloplasty (7.7%). Half of procedures (n = 13) were performed by surgeons with extensive RS experience (more than 150 procedures). Per procedure, there was a median (quartiles) of 9 (7; 11) near-miss events. There was 1 (0; 2) major near-miss events, with no harm. The median NTSRS score was 18 (14; 21), out of 40. The number of near-miss events was strongly correlated with the NTSRS score (r = - 0.92, p < 0.001) but was not correlated with the surgeon's experience. The surgeons for fifteen (58%) procedures, and the bed-side surgeons for 11 (42%) procedures, felt that there was no need for an improvement in the quality of their NTS. None of the surgeons gave a negative self-evaluation for any procedure; in three procedures (12%), the bed-side surgeons self-assessed negatively, on ergonomics. CONCLUSION: Occurrence of near-miss events was reduced in teams managing NTS. Specific NTS surgical team training is essential for robotic surgery as it may have a significant impact on risk management.

Short Leukocyte Telomere Length Precedes Clinical Expression of Atherosclerosis: The Blood-and-Muscle Model.

RATIONALE: Short telomere length (TL) in leukocytes is associated with atherosclerotic cardiovascular disease (ASCVD). It is unknown whether this relationship stems from having inherently short leukocyte TL (LTL) at birth or a faster LTL attrition thereafter. LTL represents TL in the highly proliferative hematopoietic system, whereas TL in skeletal muscle represents a minimally replicative tissue. OBJECTIVE: We measured LTL and muscle TL (MTL) in the same individuals with a view to obtain comparative metrics for lifelong LTL attrition and learn about the temporal association of LTL with ASCVD. METHODS AND RESULTS: Our Discovery Cohort comprised 259 individuals aged 63±14 years (mean±SD), undergoing surgery with (n=131) or without (n=128) clinical manifestation of ASCVD. In all subjects, MTL adjusted for muscle biopsy site (MTLA) was longer than LTL and the LTL-MTLA gap similarly widened with age in ASCVD patients and controls. Age- and sex-adjusted LTL (P=0.005), but not MTLA (P=0.90), was shorter in patients with ASCVD than controls. The TL gap between leukocytes and muscle (LTL-MTLA) was wider (P=0.0003), and the TL ratio between leukocytes and muscle (LTL/MTLA) was smaller (P=0.0001) in ASCVD than in controls. Findings were replicated in a cohort comprising 143 individuals. CONCLUSIONS: This first study to apply the blood-and-muscle TL model shows more pronounced LTL attrition in ASCVD patients than controls. The difference in LTL attrition was not associated with age during adulthood suggesting that increased attrition in early life is more likely to be a major explanation of the shorter LTL in ASCVD patients. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT02176941.

Cost-effectiveness of four living-donor nephrectomy techniques from a hospital perspective.

BACKGROUND: In Europe, transplantation centres use different nephrectomy techniques: open surgery, and standard, hand-assisted and robot-assisted laparoscopies. Few studies have analysed the disparity in costs and clinical outcomes between techniques. Since donors are healthy patients expecting minimum pain and fast recovery, this study aimed to compare the cost-effectiveness of four nephrectomy techniques focusing on early surgical outcomes, an essential in the donation act. METHODS: A micro-costing approach was used to estimate the cost of implementation from a hospital perspective. Estimates took into account sterilization costs for multiple-use equipment, costs for purchasing single-use equipment, staff and analgesics. The study recruited donors in 20 centres in France. Quality of life by EuroQol-5D was assessed preoperatively, and 4 and 90 days post-operatively. Two effectiveness indicators were built: quality-of-life recovery and post-operative pain days averted (PPDA). The study was registered at ClinicalTrials.gov NCT02830568, on 10 June 2010. RESULTS: A total of 264 donors were included; they underwent open surgery (n = 65), and standard (n = 65), hand-assisted (n = 65) and robot-assisted laparoscopies (n = 69). Use of the nephrectomy techniques differed greatly in cost of implementation and immediate post-operative outcomes but not in clinical outcomes at 90 days. At 4 days, hand-assisted laparoscopy provided the lowest cost per quality-of-life recovery unit of effectiveness (%) and PPDA (days) (€2056/40.1%/2.3 days, respectively). Robot-assisted laparoscopy was associated with the best post-operative outcomes but with the highest cost (€3430/59.1%/2.6 days). CONCLUSION: Hand-assisted, standard and robot-assisted laparoscopies are cost-effective techniques compared with open surgery. Hand-assisted surgery is the most cost-effective procedure. Robot-assisted surgery requires more healthcare resource use but enables the best clinical outcome.

Effectiveness of an Integrated Video Recording and Replaying System in Robotic Surgical Training.

OBJECTIVE: This study evaluated the effectiveness of using a video recording and replaying system in robotic surgical training. SUMMARY BACKGROUND DATA: Robotic surgical videos are reviewed to accelerate the acquisition of robotic surgical skills. However, few professional recording and replaying systems have been used during robotic surgical training. The effectiveness of these professional video systems should be investigated and validated. METHODS: A randomized study was conducted to analyze the performance of 60 participants, who were unfamiliar with surgical robotics, in a robotic simulator. Participants were enrolled in 2 groups to perform 2 exercises on a Mimic dV-Trainer. One group was trained with the new protocol based on a recording and replaying system (controller of events on simulator and robot) and the other group was trained with the conventional method. The overall scores were automatically evaluated by the simulator. The number of additional requests for reviewing the videos or watching the trainer's demonstration and the learning curves based on the overall scores were compared between the 2 groups. RESULTS: The group trained with controller of events on simulator and robot presented a significantly improved learning curve in both exercises (P < 0.001) with more additional requests (P < 0.001) in comparison with the group trained with the conventional method. CONCLUSIONS: In robotic skills training, the use of a recording and replay system is beneficial and more efficient than the conventional training method.

Nephrectomy Complication Is a Risk Factor of Clinically Meaningful Decrease in Health Utility among Living Kidney Donors.

OBJECTIVES: To assess the clinically relevant change in health state utility (HSU) in living kidney donors and whether this change value is constant across measures and clinical conditions and is useful for health economics studies. We aimed to 1) measure the change in the HSU score for living kidney donors from before donation to 3 months after donation and 2) estimate the minimal important decrease (MIDe) in the HSU score for living kidney donors and its associated clinical factors. METHODS: Data from a prospective multicenter observational study measuring quality of life of kidney donors by the three-level EuroQol five-dimensional questionnaire (EQ-5D-3L) and the six-dimensional health state short form (SF-6D) before donation and at 3 months after donation provided HSU scores. Two methods were used to derive the MIDe: the anchor-based method and the distribution-based (standard error of measurement) method. Logistic regression was used to identify clinical factors associated with the MIDe after donation. RESULTS: In total, 228 and 216 donors completed the EQ-5D-3L and the SF-6D, respectively. Mean HSU scores were 0.932 and 0.823 before donation and 0.895 and 0.764 at 3 months after donation. HSU scores were significantly decreased at 3 months, and 18.5% of donors rated their global health as "somewhat worse." By the EQ-5D-3L and the SF-6D, the MIDe was estimated at -0.113 and -0.116 with the anchor-based method and -0.075 and -0.077 with the distribution-based method. Risk of decreased HSU score was significantly associated with clinical complications but only marginally with surgical technique. CONCLUSIONS: A short-term clinically relevant decrease in HSU was significantly associated with clinical complications in kidney donors. Preventing perioperative complications is of prime importance in kidney donation.

"Alarm-corrected" ergonomic armrest use could improve learning curves of novices on robotic simulator.

BACKGROUND: In robotic surgery, the professional ergonomic habit of using an armrest reduces operator fatigue and increases the precision of motion. We designed and validated a pressure surveillance system (PSS) based on force sensors to investigate armrest use. The objective was to evaluate whether adding an alarm to the PSS system could shorten ergonomic training and improve performance. STUDY DESIGN: Twenty robot and simulator-naïve participants were recruited and randomized in two groups (A and B). The PSS was installed on a robotic simulator, the dV-Trainer, to detect contact with the armrest. The Group A members completed three tasks on the dV-Trainer without the alarm, making 15 attempts at each task. The Group B members practiced the first two tasks with the alarm and then completed the final tasks without the alarm. The simulator provided an overall score reflecting the trainees' performance. We used the new concept of an "armrest load" score to describe the ergonomic habit of using the armrest. RESULTS: Group B had a significantly higher performance score (p < 0.001) and armrest load score (p < 0.001) than Group A from the fifth attempt of the first task to the end of the experiment. CONCLUSIONS: Based on the conditioned reflex effect, the alarm associated with the PSS rectified ergonomic errors and accelerated professional ergonomic habit acquisition. The combination of the PSS and alarm is effective in significantly shortening the learning curve in the robotic training process.

Face, content, construct, and concurrent validity of a novel robotic surgery patient-side simulator: the Xperience™ Team Trainer.

OBJECTIVES: To determine the face, content, construct, and concurrent validity of the Xperience™ Team Trainer (XTT) as an assessment tool of robotic surgical bed-assistance skills. METHODS: Subjects were recruited during a robotic surgery curriculum. They were divided into three groups: the group RA with robotic bed-assistance experience, the group LS with laparoscopic surgical experience, and the control group without bed-assistance or laparoscopic experience. The subjects first performed two standard FLS exercises on a laparoscopic simulator for the assessment of basic laparoscopic skills. After that, they performed three virtual reality exercises on XTT, and then performed similar exercises on physical models on a da Vinci(®) box trainer. RESULTS: Twenty-eight persons volunteered for and completed the tasks. Most expert subjects agreed on the realism of XTT and the three exercises, and also their interest for teamwork and bed-assistant training. The group RA and the group LS demonstrated a similar level of basic laparoscopic skills. Both groups performed better than the control group on the XTT exercises (p < 0.05). The performance superiority of the group RA over LS was observed but not statistically significant. Correlation of performance was determined between the tests on XTT and on da Vinci(®) box trainer. CONCLUSIONS: The introduction of XTT facilitates the training of bedside assistants and emphasizes the importance of teamwork, which may change the paradigm of robotic surgery training in the near future. As an assessment tool of bed-assistance skills, XTT proves face, content, and concurrent validity. However, these results should be qualified considering the potential limitations of this exploratory study with a relatively small sample size. The training modules remain to be developed, and more complex and discriminative exercises are expected. Other studies will be needed to further determine construct validity in the future.

[Removal and transplant, synchronised surgical procedures]. / Prélèvement et greffe, des temps chirurgicaux synchronisés.

Since 2001, the team of the organ and tissue procurement unit of Nancy general hospital has practised the minimally invasive laparoscopic organ removal procedure through robot-assisted surgery. Here the team shares its expertise in the area of kidney removal from a living donor. Perfectly synchronised with the procedure of the team in charge of the transplant, the surgical stages are carried out in sequence ensuring optimal safety for the donor and recipient.

Development of a standardised training curriculum for robotic surgery: a consensus statement from an international multidisciplinary group of experts.

OBJECTIVES: To explore the views of experts about the development and validation of a robotic surgery training curriculum, and how this should be implemented. MATERIALS AND METHODS: An international expert panel was invited to a structured session for discussion. The study was of a mixed design, including qualitative and quantitative components based on focus group interviews during the European Association of Urology (EAU) Robotic Urology Section (ERUS) (2012), EAU (2013) and ERUS (2013) meetings. After introduction to the aims, principles and current status of the curriculum development, group responses were elicited. After content analysis of recorded interviews generated themes were discussed at the second meeting, where consensus was achieved on each theme. This discussion also underwent content analysis, and was used to draft a curriculum proposal. At the third meeting, a quantitative questionnaire about this curriculum was disseminated to attendees to assess the level of agreement with the key points. RESULTS: In all, 150 min (19 pages) of the focus group discussion was transcribed (21 316 words). Themes were agreed by two raters (median agreement κ 0.89) and they included: need for a training curriculum (inter-rater agreement κ 0.85); identification of learning needs (κ 0.83); development of the curriculum contents (κ 0.81); an overview of available curricula (κ 0.79); settings for robotic surgery training ((κ 0.89); assessment and training of trainers (κ 0.92); requirements for certification and patient safety (κ 0.83); and need for a universally standardised curriculum (κ 0.78). A training curriculum was proposed based on the above discussions. CONCLUSION: This group proposes a multi-step curriculum for robotic training. Studies are in process to validate the effectiveness of the curriculum and to assess transfer of skills to the operating room.

National prospective study on the use of local haemostatic agents during partial nephrectomy.

OBJECTIVE: To assess the use of local haemostatic agents (HAs) in a prospective multicentre large series of partial nephrectomies (PNs). PATIENTS AND METHODS: Prospective National Observational Registry on the Practices of Haemostasis in Partial Nephrectomy (NEPHRON): the study was conducted in 54 French urological centres from 1 June to 31 December 2010. In all, 570 consecutive patients undergoing a PN were enrolled in this study in a prospective manner. The data was collected prospectively via an electronic case-report form: five different sheets were included for preoperative, perioperative, postoperative and follow-up data respectively. Information related to haemostasis was analysed. RESULTS: The median patient age was 60 years and the mean (range) tumour size was 3.68 (0.19-15) cm. An HA was primarily used in 71.4% of patients, with a statistically significant difference among surgical approaches (P = 0.024). In 91.8% of cases, a single use of a HA was sufficient for achieving haemostasis. The HA was used either alone (13.9%) or in association with sutures (80.3%). One or more additional haemostatic action(s) was needed in 12.3% of the cases. When comparing patients who received a HA with those who did not receive a HA, there was no statistical difference between the groups for tumour size (P = 0.542), collecting system drainage (P = 0.538), hospital stay (P = 0.508), operation time (P = 0.169), blood loss (P = 0.387) or transfusion rate (P = 0.713). CONCLUSION: HAs are widely used by urologists during PN. Progress is needed for standardising HA application, especially for the timing of application. For the time being, the role of the HA in nephron-sparing surgery is still to be evaluated.

Determination of the latency effects on surgical performance and the acceptable latency levels in telesurgery using the dV-Trainer(®) simulator.

BACKGROUND: The primary limitation of telesurgery is the communication latency. Accurate and detailed data are lacking to reveal the latency effects on surgical performance; furthermore, the maximum acceptable latency in telesurgery remains unclear. METHODS: Sixteen medical students performed an energy dissection exercise and a needle-driving exercise on the robotic simulator dV-Trainer(®), and latencies varying between 0 and 1,000 ms with a 100-ms interval were randomly and blindly presented. Task completion time, instrument motion, and errors were automatically recorded. The difficulty, security, precision, and fluidity of manipulation were self-scored by subjects between 0 and 4 (0 the best, 2 moderate, and 4 the worst). RESULTS: Task completion time, motion, and errors increased gradually as latency increased. An exponential regression was fit to the mean times and motions (R (2) > 0.98). Subjective scorings of the four items were similar. The mean scores were less than 1 at delays ≤200 ms, then increased from 1 to 2 at 300-700 ms, and finally approached 3 at delays above. In both exercises, latencies ≤300 ms were judged to be safe by all and 400-500 ms were accepted by 66-75 % of subjects. Less than 20 % of subjects accepted delays ≥800 ms. CONCLUSIONS: The surgical performance deteriorates in an exponential way as the latency increases. The delay impact on instrument manipulation is mild at 0-200 ms, then increases from small to large at 300-700 ms, and finally becomes very large at 800-1,000 ms. Latencies ≤200 ms are ideal for telesurgery; 300 ms is also suitable; 400-500 ms may be acceptable but are already tiring; and 600-700 ms are difficult to deal with and only acceptable for low risk and simple procedures. Surgery is quite difficult at 800-1,000 ms, telementoring would be a better choice in this case.

Is an extended 20-core prostate biopsy protocol more efficient than the standard 12-core? A randomized multicenter trial.

PURPOSE: We determined the impact of increasing the number of cores from 12 to 20 at initial prostate biopsy in men suspicious of prostate cancer. MATERIALS AND METHODS: From December 2009 to November 2011, patients in 7 centers scheduled for a first prostate biopsy, with a prostate specific antigen less than 20 ng/ml and no nodule on digital rectal examination, were invited to participate in this superiority trial. Patients were randomized to a 12-core (PB12 group) or a 20-core (PB20 group) protocol. The primary end point was cancer detection rate. Secondary end points were cancer characteristics, rate of complications and patient tolerance assessed by a self-completed booklet before prostate biopsy and at day 5 and day 15. RESULTS: A total of 339 patients were randomized. Preoperative variables were similar in both groups. Cancer was detected in 71 patients (42.0%) in PB12 group and in 81 patients (48.8%) in PB20 group, and the difference was not significant (p >0.2). Gleason score and cancer length measured on prostate biopsy cores were not significantly different between groups. Although the cancer detection rate was linked to prostate volume, this was not affected by the number of extracted cores (p >0.4). Complications number and seriousness were comparable in both arms. No significant difference was noted regarding side effects and tolerance as self-assessed by the patient at day 5 and day 15 after prostate biopsy. CONCLUSIONS: Our findings suggest that there is no significant advantage in using a 20-core biopsy protocol vs 12-core protocol during an initial prostate biopsy.

Clinical and oncological outcomes of open partial nephrectomy versus robot assisted partial nephrectomy over 15 years.

Partial nephrectomy (PN) is the gold standard surgical treatment for localized kidney cancer. The objective of our study was to compare clinical and perioperative outcomes of open partial nephrectomy (OPN) and robotic-assisted partial nephrectomy (RAPN). We retrospectively collected all patients who underwent PN for kidney cancer between 2007 and 2019 at two French academic urology departments. Clinical and perioperative outcomes and complications were compared between the OPN group and the RAPN group. Recurrence-free survival (RFS) and overall survival (OS) were compared using the log-rank test. We included 405 patients. The maximum follow-up time was 13.6 years in the OPN group and 7.1 years in the RAPN group. The OPN group was associated with more blood loss and longer hospital stay (respectively, 287 ml vs. 62.1 ml; p < 0.001 and 8.54 days vs. 4.96 days; p < 0.001). Ischemia time was shorter in the OPN group (11.4 min vs. 16.9 min; p < 0.001). The rate of complications during hospitalization and after discharge from hospital was higher in the OPN group (respectively, n = 51 vs. 30; p = 0.031 and n = 31 vs. 14; p < 0.001). RFS and OS were similar in both groups. In our study, RAPN has better perioperative outcomes with shorter hospital stay and less blood loss but also fewer early and late complications. However, we did not find any difference in terms of RFS and OS.

Impact of paternal age on assisted reproductive technology outcomes and offspring health: a systematic review.

BACKGROUND: The increase in paternal age and the percentage of births after assisted reproductive technologies (ART) may have consequences on offspring and society's position regarding access to ART must be questioned. Most countries recommend limiting ART to men under 60 years. What is the rationale for this threshold? OBJECTIVE: This systematic review assesses scientific arguments to establish links between paternal age, male fertility, and offspring health. MATERIAL AND METHODS: Using the PRISMA guidelines, this systematic review of the literature analyzed 111 articles selected after screening PubMed, ScienceDirect, and Web of Science for articles published between January 1, 1995 and December 31, 2021. RESULTS: A strong correlation was highlighted between advanced paternal age and a decrease of some sperm parameters (semen volume and sperm motility) and infant morbidity (exponentially increased incidence of achondroplasia and Apert syndrome, and more moderately increased incidence of autism and schizophrenia). The impact of paternal age on pregnancy and fetal aneuploidy rates is more controversial. No association was found with spontaneous abortion rates. DISCUSSION AND CONCLUSION: The scientific parameters should be explained to older parents undergoing ART. And for countries that discuss a limit on paternal age for access to ART, the debate requires consideration of social and ethical arguments.

Effectiveness of a vision-based handle trajectory monitoring system in studying robotic suture operation.

Data on surgical robots are not openly accessible, limiting further study of the operation trajectory of surgeons' hands. Therefore, a trajectory monitoring system should be developed to examine objective indicators reflecting the characteristic parameters of operations. 20 robotic experts and 20 first-year residents without robotic experience were included in this study. A dry-lab suture task was used to acquire relevant hand performance data. Novices completed training on the simulator and then performed the task, while the expert team completed the task after warm-up. Stitching errors were measured using a visual recognition method. Videos of operations were obtained using the camera array mounted on the robot, and the hand trajectory of the surgeons was reconstructed. The stitching accuracy, robotic control parameters, balance and dexterity parameters, and operation efficiency parameters were compared. Experts had smaller center distance (p < 0.001) and larger proximal distance between the hands (p < 0.001) compared with novices. The path and volume ratios between the left and right hands of novices were larger than those of experts (both p < 0.001) and the total volume of the operation range of experts was smaller (p < 0.001). The surgeon trajectory optical monitoring system is an effective and non-subjective method to distinguish skill differences. This demonstrates the potential of pan-platform use to evaluate task completion and help surgeons improve their robotic learning curve.