The 2012 Briganti nomogram predicts disease progression after surgery in high-risk prostate cancer patients.

Objectives: We tested whether the 2012 Briganti nomogram for the risk of pelvic lymph node invasion (PLNI) may represent a predictor of disease progression after surgical management in high-risk (HR) prostate cancer (PCa) patients according to the European Association of Urology. Methods: Between January 2013 and December 2021, HR PCa patients treated with robot-assisted radical prostatectomy (RARP) and extended pelvic lymph node dissection (ePLND) were identified. The 2012 Briganti nomogram was evaluated as a continuous and categorical variable, which was dichotomized using the median. The risk of disease progression, defined as the event of biochemical recurrence and/or local recurrence/distant metastases was assessed by Cox regression models. Results: Overall, 204 patients were identified. The median 2012 Briganti nomogram score resulted 12.0% (IQR: 6.0-22.0%). PLNI was detected in 57 (27.9%) cases. Compared to patients who had preoperatively a 2012 Briganti nomogram score ≤12%, those with a score >12% were more likely to present with higher percentage of biopsy positive cores, palpable tumors at digital rectal examination, high-grade cancers at prostate biopsies, and unfavorable pathology in the surgical specimen. At multivariable Cox regression analyses, disease progression, which occurred in 85 (41.7%) patients, was predicted by the 2012 Briganti nomogram score (HR: 1.02; 95%CI: 1.00-1.03; p = 0.012), independently by tumors presenting as palpable (HR: 1.78; 95%CI: 1.10.2.88; p = 0.020) or the presence of PLNI in the surgical specimen (HR: 3.73; 95%CI: 2.10-5.13; p = 0.012). Conclusions: The 2012 Briganti nomogram represented an independent predictor of adverse prognosis in HR PCa patients treated with RARP and ePLND. As the score increased, so patients were more likely to experience disease progression, independently by the occurrence of PLNI. The association between the nomogram, unfavorable pathology and tumor behavior might turn out to be useful for selecting a subset of patients needing different treatment paradigms in HR disease.

3D monitors improve performance on the HUGO™ RAS system: a randomised trial.

BACKGROUND: Robot-assisted surgery is used worldwide, allowing surgeons to perform complex surgeries with increased precision and flexibility. It offers technical benefits compared to traditional laparoscopic surgery due to its utilization of both 3D vision and articulated instruments. The objective was to investigate the isolated effect of 3D- versus 2D monitors when working with articulated instruments in robot-assisted surgery. METHODS: Surgical novices (medical students, n = 31) were randomized to simulation-based training with either the 3D vision switched on or off. Both groups completed each of the four exercises six times over two sessions on the Medtronic Hugo™ RAS system simulator. The outcome was the simulator performance parameters and a visual discomfort questionnaire. RESULTS: For the efficiency parameters, we found that both groups improved over time (p < 0.001) and that the intervention group (3D) consistently outperformed the control (2D) group (p < 0.001). On the other hand, we didn't find any significant difference in the error metrics, such as drops (p-values between 0.07 and 0.57) and instrument collisions (p-values between 0.09 and 0.26). Regarding Visual Discomfort, it was significantly more difficult for the 3D group to focus (p = 0.001). CONCLUSION: 3D monitors for an open robotic console improve efficiency and speed compared to 2D monitors in a simulated setting when working with articulated instruments.

Comparative analysis of safety and effectiveness between natural orifice specimen extraction and conventional transabdominal specimen extraction in robot-assisted colorectal cancer resection through systematic review and meta-analysis.

The goal of this systematic review and meta-analysis is to evaluate the perioperative and oncologic results of natural orifice specimen extraction (NOSE) compared to conventional transabdominal specimen extraction (TASE) in robotic-assisted surgery for colorectal cancer. A comprehensive electronic search will be performed on PubMed, Embase, and the Cochrane Library to find research articles published from the beginning of the databases to July 2024 that focus on patients who have undergone robotic-assisted surgery for colorectal cancer. Specifically, this review will compare NOSE with conventional TASE. Only studies published in English will be considered. Literature screening will adhere closely to predetermined criteria for inclusion and exclusion, specifically targeting randomized controlled trials and cohort studies. The evaluation of quality will involve the use of the Newcastle-Ottawa Scale (NOS). Meta-analysis of the included studies' data will be performed using Review Manager 5.4.1. In the final analysis, 9 retrospective cohort studies comprising 1571 patients were included. Out of these, 732 patients opted for NOSE, while 839 patients chose conventional TASE in robotic colorectal surgery. Patients who received TASE experienced enhancements in hospital stay duration, time until first gas passage, wound infection rates, and time until the first intake of a liquid diet. Nevertheless, there were no notable distinctions noted between the two methods regarding surgery duration, projected blood loss, intestinal blockage, or frequency of anastomotic leakage. In patients undergoing robotic-assisted colorectal surgery, the safety and feasibility of NOSE are demonstrated. Compared to traditional TASE, it provides clear benefits including shorter hospital stays, earlier first flatus, quicker initiation of a liquid diet, and lower risk of wound infection.

How i do it: Robot-assisted transcerebellar stereotactic approach for brainstem lesion.

BACKGROUND: Stereotactic approaches to diffuse intrinsic pontine gliomas (DIPGs) remain essential due to advances in molecular biology and management, necessitating tissue sampling. Here we present an effective technique with a biopsy by robot-assisted transcerebellar approach. METHOD: Our procedure was performed using the ROSA robotic system and the OARM CT scan, which provided stereotactic conditions for this transcerebellar approach to brainstem lesions. CONCLUSION: The robot-assisted transcerebellar stereotactic approach remains essential to provide complications for biopsy of brainstem lesions.

Implementation and Utility of the Da Vinci SP (Single Port) in Pediatric Urology.

PURPOSE OF REVIEW: Detail the evolution, utility, and future directions of the da Vinci SP® in pediatric urology, focusing on perioperative outcomes and intraoperative details. RECENT FINDINGS: The SP has been safely and successfully utilized in various pediatric urological procedures, from pyeloplasty to nephroureterectomy to appendicovesicostomy. Reports indicate mixed operative times but similar hospital stays and postoperative outcomes compared to multiport (MP) robotic surgery. The learning curve for transitioning from MP to SP systems in pediatric patients appears manageable, though the smaller abdominal circumference in children poses a notable challenge. This review assumes that SP systems will primarily be acquired for adult services, not considering initial and ongoing costs to hospital systems. The SP serves as a complementary option, rather than a replacement, for MP robotic surgery in pediatric urology, offering potential advantages in specific scenarios. Cosmetic outcomes with the SP appear at least as favorable as MP surgery, but further research is needed. Future research should focus on patient-centered outcomes to optimize SP robotic surgery use in pediatric patients.

Fellow perceptions of robotic surgery preparedness for fellowship.

INTRODUCTION: Many surgical fellowship programs incorporate robotic surgery, yet not all residency programs offer robotic training for residents. Given the variability of pre-fellowship robotic exposure, the goal of this study was to explore whether standardized robotic skills assessment would be useful to fellows at the start of their training. METHODS: In partnership with the Fellowship Council, we surveyed current fellows of accredited Thoracic, Colorectal, HPB, and Advanced GI/MIS/Bariatrics/Foregut Fellowship programs. Main outcome measurements included amount of robotic exposure during residency, fellows' robotic skills at the start of fellowship, and fellows' attitudes towards a standardized skills assessment. RESULTS: In total, 78 fellows completed the survey. Mean percentage of cases performed robotically during fellowship was 38.1% (SD ± 32.25%). From our respondents, 46% had no robotic curriculum during residency and 86.9% felt a standardized robotic curriculum during residency would have been beneficial. When asked if they started fellowship with adequate robotic skills to operate autonomously, 31% strongly agreed, but 24.4% strongly disagreed. The majority of fellows reported their fellowship program did not conduct an assessment of their robotic skills (71.5%), or provide a specific robotic curriculum (75.6%). On the other hand, 73.3% felt a formal proficiency assessment at the start of fellowship would be helpful for individualized support and training. CONCLUSIONS: Given the significant variability in resident exposure to robotic surgery, a standardized robotic curriculum during residency would likely be beneficial. Additionally, a robotic skills assessment at the start of fellowship could help provide a tailored training experience for fellows interested in this skillset.

Objective performance indicators versus GEARS: an opportunity for more accurate assessment of surgical skill.

PURPOSE: Surgical skill evaluation that relies on subjective scoring of surgical videos can be time-consuming and inconsistent across raters. We demonstrate differentiated opportunities for objective evaluation to improve surgeon training and performance. METHODS: Subjective evaluation was performed using the Global evaluative assessment of robotic skills (GEARS) from both expert and crowd raters; whereas, objective evaluation used objective performance indicators (OPIs) derived from da Vinci surgical systems. Classifiers were trained for each evaluation method to distinguish between surgical expertise levels. This study includes one clinical task from a case series of robotic-assisted sleeve gastrectomy procedures performed by a single surgeon, and two training tasks performed by novice and expert surgeons, i.e., surgeons with no experience in robotic-assisted surgery (RAS) and those with more than 500 RAS procedures. RESULTS: When comparing expert and novice skill levels, OPI-based classifier showed significantly higher accuracy than GEARS-based classifier on the more complex dissection task (OPI 0.93 ± 0.08 vs. GEARS 0.67 ± 0.18; 95% CI, 0.16-0.37; p = 0.02), but no significant difference was shown on the simpler suturing task. For the single-surgeon case series, both classifiers performed well when differentiating between early and late group cases with smaller group sizes and larger intervals between groups (OPI 0.9 ± 0.08; GEARS 0.87 ± 0.12; 95% CI, 0.02-0.04; p = 0.67). When increasing the group size to include more cases, thereby having smaller intervals between groups, OPIs demonstrated significantly higher accuracy (OPI 0.97 ± 0.06; GEARS 0.76 ± 0.07; 95% CI, 0.12-0.28; p = 0.004) in differentiating between the early/late cases. CONCLUSIONS: Objective methods for skill evaluation in RAS outperform subjective methods when (1) differentiating expertise in a technically challenging training task, and (2) identifying more granular differences along early versus late phases of a surgeon learning curve within a clinical task. Objective methods offer an opportunity for more accessible and scalable skill evaluation in RAS.

Combined robotic surgery for concomitant treatment of endometrial cancer and obesity.

BACKGROUND: Endometrial Cancer (EC) is strongly linked to obesity. Bariatric surgery is recognized as a long-term solution for weight loss in severely obese patients. This pilot study investigates the feasibility, intraoperative and 30-day morbidity outcomes of integrating gynecological surgical staging and bariatric robotic surgery in class II and III obese patients affected by early EC or Endometrial Intraepithelial Neoplasia (EIN). METHODS: Patients aged over 18 years old with early EC or EIN and class II and III obesity (Body mass index (BMI) ≥ 35 kg/m2) who are surgical and anesthesiologic candidates. Standard robotic surgery for early EC staging performed alone (THBSO group) or in conjunction with sleeve gastrectomy (THBSO + SG group) for obesity management was proposed. RESULTS: Of the 13 patients who met the inclusion criteria, 5 (38.46%) opted for combined surgery. The groups showed a significant difference in preoperative BMI (49.68 kg/m2 vs. 40.24 kg/m2 p = 0.017 with and without SG), preoperative weight (143.92 kg vs. 105.62 kg p = 0.004 with and without SG), preoperative (p = 0.01) and postoperative (p = 0.005) aspartate transaminase (AST). The THBSO + SG group had higher anesthesia induction end-tidal carbon dioxide (ETCO2) (p = 0.05), final Partial pressure of carbon dioxide (PaCO2) (p = 0.044), anesthesia induction lactate (p = 0.001) and final lactate (p = 0.011) without a significant difference in final pH (p = 0.31). Operative time was longer in the THBSO + SG group (p < 0.001), but this did not result in longer ICU (p = 0.351), total hospital stays (p = 0.208), nor increased blood loss and transfusion. The simultaneous combined approach had an 80% success rate. At 6 months, the THBSO + SG group achieved significantly greater weight loss than the THBSO group (ΔBMI - 11.81 kg/m2 vs - 1.72 kg/m2, p = 0.003, with and without SG). CONCLUSION: Integrating robotic EC staging with SG in obese women with early EC increased the operative time without increasing intraoperative risks, early and 30 days post-surgery complication and offering a promising approach to simultaneously treating both conditions.

A multi-docking strategy for robotic LAR and deep pelvic surgery with the Hugo RAS system: experience from a tertiary referral center.

INTRODUCTION: In June 2023, our institution adopted the Medtronic Hugo RAS system for colorectal procedures. This system's independent robotic arms enable personalized docking configurations. This study presents our refined multi-docking strategy for robotic low anterior resection (LAR) and deep pelvic procedures, designed to maximize the Hugo RAS system's potential in rectal surgery, and evaluates the associated learning curve. METHODS: This retrospective analysis included 31 robotic LAR procedures performed with the Hugo RAS system using our novel multi-docking strategy. Docking times were the primary outcome. The Mann-Kendall test, Spearman's correlation, and cumulative sum (CUSUM) analysis were used to assess the learning curve and efficiency gains associated with the strategy. RESULTS: Docking times showed a significant negative trend (p < 0.01), indicating improved efficiency with experience. CUSUM analysis confirmed a distinct learning curve, with proficiency achieved around the 15th procedure. The median docking time was 6 min, comparable to other robotic platforms after proficiency. CONCLUSION: This study demonstrates the feasibility and effectiveness of a multi-docking strategy in robotic LAR using the Hugo RAS system. Our personalized approach, capitalizing on the system's unique features, resulted in efficient docking times and streamlined surgical workflow. This approach may be particularly beneficial for surgeons transitioning from laparoscopic to robotic surgery, facilitating a smoother adoption of the new technology. Further research is needed to validate the generalizability of these findings across different surgical settings and experience levels.