Video-based peer feedback through social networking for robotic surgery simulation: a multicenter randomized controlled trial.

OBJECTIVE: To examine the feasibility and outcomes of video-based peer feedback through social networking to facilitate robotic surgical skill acquisition. BACKGROUND: The acquisition of surgical skills may be challenging for novel techniques and/or those with prolonged learning curves. METHODS: Randomized controlled trial involving 41 resident physicians performing the Tubes (Da Vinci Intuitive Surgical, Sunnyvale, CA) simulator exercise with versus without peer feedback of video-recorded performance through a social networking Web page. Data collected included simulator exercise score, time to completion, and comfort and satisfaction with robotic surgery simulation. RESULTS: There were no baseline differences between the intervention group (n = 20) and controls (n = 21). The intervention group showed improvement in mean scores from session 1 to sessions 2 and 3 (60.7 vs 75.5, P < 0.001, and 60.7 vs 80.1, P < 0.001, respectively). The intervention group scored significantly higher than controls at sessions 2 and 3 (75.5 vs 59.6, P = 0.009, and 80.1 vs 65.9, P = 0.019, respectively). The mean time (seconds) to complete the task was shorter for the intervention group than for controls during sessions 2 and 3 (217.4 vs 279.0, P = 0.004, and 201.4 vs 261.9, P = 0.006, respectively). At the study conclusion, feedback subjects were more comfortable with robotic surgery than controls (90% vs 62%, P = 0.021) and expressed greater satisfaction with the learning experience (100% vs 67%, P = 0.014). Of the intervention subjects, 85% found that peer feedback was useful and 100% found it effective. CONCLUSIONS: Video-based peer feedback through social networking appears to be an effective paradigm for surgical education and accelerates the robotic surgery learning curve during simulation.

Population-based assessment of prostate-specific antigen testing for prostate cancer in the elderly.

OBJECTIVES: To perform a population-based analysis to characterize the effect of prostate-specific antigen (PSA) testing on oncologic outcomes in men diagnosed with prostate cancer. MATERIALS AND METHODS: We used the Surveillance, Epidemiology, and End Results-Medicare-linked data to identify 98,883 men diagnosed with prostate cancer from 1996 to 2007. We stratified frequency of PSA testing as none, 1 to 2, 3 to 5, and≥6 tests in the 5 years before prostate cancer diagnosis. We used propensity scoring methods to assess the effect of frequency of PSA testing on likelihood of (1) metastases at diagnosis and (2) overall mortality and prostate cancer-specific mortality. RESULTS: In adjusted analyses, the likelihood of being diagnosed with metastatic prostate cancer decreased with greater frequency of PSA testing (none, 10.6; 1-2, 8.3; 3-5, 3.7; and≥6, 2.5 events per 100 person years, P<0.001). Additionally, greater frequency of PSA testing was associated with improved overall survival and prostate cancer-specific survival (P<0.001 for both). CONCLUSIONS: Greater frequency of PSA testing in men 70 years of age or older in the 5 years before prostate cancer diagnosis is associated with lower likelihood of being diagnosed with metastatic prostate cancer and improved overall and prostate cancer-specific survival.

The impact of radical prostatectomy operative time on outcomes and costs.

OBJECTIVE: To examine the impact of radical prostatectomy (RP) operative time on outcomes and cost, we performed a population-based assessment of operative time as a predictor of outcomes. Although operative time has been used as a metric to evaluate RP surgeon learning curves, the effect of RP operative times on outcomes remains understudied. MATERIALS AND METHODS: We used US Surveillance, Epidemiology, and End Results-Medicare linked data to identify 7534 men aged≥66 years diagnosed with prostate cancer during 2003-2007 who underwent RP for localized prostate cancer through 2009. We categorized RP operative time into quartiles (short, intermediate, long, and very long) and used propensity score analyses to assess its impact on perioperative complications, mortality, length of hospitalization, readmissions, emergency room visits, and costs. RESULTS: Quartiles ranged from 0 to 172 minutes for short, 173 to 214 minutes for intermediate, 215 to 268 minutes for long, and ≥269 minutes for very long RP operative times. After propensity score adjustment, longer operative time was associated with more surgery-related complications (short, 12.0%; intermediate, 12.3%; long, 14.4%; and very long, 22.8%; P<.001), longer median (interquartile range) length of stay in days (short, 2 [2-3]; intermediate, 2 [2-3]; long, 2 [1-3]; and very long, 2 [1-3]; P<.001), and higher median costs (short, $10,647; intermediate, $10,957; long, $11,405; and very long, $11,966; P<.001). CONCLUSION: Longer RP operative time is associated with more complications, longer lengths of hospital stay, and higher costs. Increasing operative efficiency may reduce complications, length of stay, and health-care costs.

Testosterone replacement therapy following the diagnosis of prostate cancer: outcomes and utilization trends.

INTRODUCTION: Late-onset hypogonadism may impair quality of life and contribute to metabolic and cardiovascular comorbidity in aging men. Testosterone replacement therapy is effective in treating hypogonadism. However, for the millions of men with a history of prostate cancer, exogenous testosterone has long been considered contraindicated, even though little data in such men are available. Clarification of this safety issue could allow treatment to be considered for a sizeable segment of the aging male population. AIM: The aim of this study is to examine population-based utilization and impact of testosterone replacement therapy in men with prostate cancer. METHODS: Using linked Surveillance, Epidemiology, and End Results-Medicare data, we identified 149,354 men diagnosed with prostate cancer from 1992 to 2007. Of those, 1181 (0.79%) men received exogenous testosterone following their cancer diagnosis. We used propensity scoring analysis to examine the effect of testosterone replacement on the use of salvage hormone therapy and overall and prostate cancer-specific mortality. MAIN OUTCOME MEASURES: We assessed overall mortality, cancer-specific mortality, and the use of salvage hormone therapy. RESULTS: Following prostate cancer diagnosis, testosterone replacement was directly related to income and educational status and inversely related to age (all P < 0.001). Men undergoing radical prostatectomy and men with well-differentiated tumors were more likely to receive testosterone (all P < 0.001). On adjusted analysis, testosterone replacement therapy was not associated with overall or cancer-specific mortality or with the use of salvage hormone therapy. CONCLUSIONS: In this population-based observational study of testosterone replacement therapy in men with a history of prostate cancer, treatment was not associated with increased overall or cancer-specific mortality. These findings suggest testosterone replacement therapy may be considered in men with a history of prostate cancer, but confirmatory prospective studies are needed.

Population-based determinants of radical prostatectomy operative time.

OBJECTIVES: To determine factors that influence radical prostatectomy (RP) operative times. Operative time assessment is inherent to defining surgeon learning curves and evaluating quality of care. SUBJECTS/PATIENTS AND METHODS: Population-based observational cohort study using USA Surveillance, Epidemiology, and End Results (SEER)-Medicare linked data of men diagnosed with prostate cancer during 2003-2007 who underwent robot-assisted radical prostatectomy (RARP, 3458 men) and retropubic RP (RRP, 6993) through to 2009. We obtained median operative time using anaesthesia administrative data for RP and used median regression to assess the contribution of patient, surgeon, and hospital factors to operative times. RESULTS: The median RARP operative time decreased from 315 to 247 min from 2003 to 2008-2009 (P < 0.001), while the median RRP operative time remained similar (195 vs 197 min, P = 0.90). In adjusted analysis, RARP vs RRP (parameter estimate [PE] 70.9; 95% confidence interval [CI] 58, 84; P < 0.001) and obesity (PE 15; 95% CI 7, 23; P < 0.001) were associated with longer operative times while higher surgeon volumes were associated with shorter operative times (P < 0.001). RPs performed by surgeons employed by group (parameter estimate [PE] -22.76; 95% CI -38, -7.49; P = 0.004) and non-government (PE -35.59; 95% CI -68.15, -3.03; P = 0.032) vs government facilities and non-profit vs government hospital ownership (PE -21.85; 95% CI -32.28, -11.42; P < 0.001) were associated with shorter operative times. CONCLUSIONS: During our study period, RARP operative times decreased by 68 min while RRP operative times remained stagnant. Higher surgeon volume was associated with shorter operative times, and selective referral or improved efficiency to the level of high-volume surgeons would net almost $15 million (USA dollars) in annual savings.

Robotic and standard open radical prostatectomy: oncological and quality-of-life outcomes.

Prostate cancer is the second leading cause of cancer death among men in the USA. Use of robot-assisted radical prostatectomy (RARP) for the management of localized prostate cancer has increased dramatically in recent years. This review focuses on comparing quality of life following RARP versus retropubic radical prostatectomy. RARP is associated with improved perioperative outcomes, such as reduced blood loss and fewer transfusions. In addition, cancer control after RARP versus retropubic radical prostatectomy is equivalent, with similar incidences of positive surgical margins and comparable early oncological outcomes. RARP appears to provide advantages in recovery of continence, potency and quality of life compared with retropubic radical prostatectomy; however, methodological limitations exist in current literature.

Does robotic prostatectomy meet its promise in the management of prostate cancer?

Following Walsh's advances in pelvic anatomy and surgical technique to minimize intraoperative peri-prostatic trauma more than 30 years ago, open retropubic radical prostatectomy (RRP) evolved to become the gold standard treatment of localized prostate cancer, with excellent long-term survival outcomes [1•]. However, RRP is performed with great heterogeneity, even among high volume surgeons, and subtle differences in surgical technique result in clinically significant differences in recovery of urinary and sexual function. Since the initial description of robotic-assisted radical prostatectomy (RARP) in 2000 [2], and U.S. Food and Drug Administration approval shortly thereafter, RARP has been rapidly adopted and has overtaken RRP as the most popular surgical approach in the management of prostate cancer in the United States [3]. However, the surgical management of prostate cancer remains controversial. This is confounded by the idolatry of new technologies and aggressive marketing versus conservatism in embracing tradition. Herein, we review the literature to compare RRP to RARP in terms of perioperative, oncologic, and quality-of-life outcomes as well as healthcare costs. This is a particularly relevant, given the absence of randomized trials and long-term (more than 10-year) follow-up for RARP biochemical recurrence-free survival.

Selective suture ligation of the dorsal vein complex during robot-assisted laparoscopic radical prostatectomy.

Technique for apical dissection and control of the dorsal vein complex (DVC) during robot-assisted laparoscopic radical prostatectomy (RALP) affects blood loss, apical positive margins, and recovery of urinary control. Over the past 7 years, our technique for apical dissection has been spurred by the overarching goal of minimizing injury to the rhabdosphincter to improve urinary continence, evolving from stapling to suture ligation of the DVC before bladder neck dissection to an athermal DVC division followed by selective suture ligation (DVC-SSL) before RALP anastomosis. Assessment of patient-reported quality of life outcomes demonstrates earlier recovery of continence with DVC-SSL.