Racial Disparities in Histology and Short-Term Renal Functional Outcomes Following Robotic Nephron-Sparing Surgery.

PURPOSE: To identify variations in renal function and histology between Caucasian Americans (CA) and African Americans (AA) undergoing robotic nephron-sparing surgery (NSS). METHODS: A retrospective chart review was performed on patients who underwent NSS. Multivariate analysis identified factors affecting postoperative estimated glomerular filtration rate (eGFR). Histology was re-reviewed by pathology to confirm papillary type. RESULTS: A total of 331 patients underwent NSS: CA (n = 212), AA (n = 105), Hispanic (n = 10), and other (n = 4). AA average age (60.1 years) was lower than CA (62.3 years) (P < .001), with a higher proportion of AA women (46%) than CA (37%) (P = .021). AA had a higher incidence of diabetes (58.2%) and hypertension (93.9%). Preoperative average eGFR was similar: 70.35 mL/min for AA versus 69.06 mL/min for CA. Average postoperative eGFR was 50.59 mL/min for AA and 57.85 mL/min for CA. Postoperative creatinine increased more in AA (0.44 mg/dL) versus CA (0.33 mg/dL) (P < .001) even when stratified by pathological stage. Clear cell renal cell carcinoma (RCC) was the most common histology with AA (45%) and CA (60%). A greater than 2-fold higher incidence of papillary RCC was observed in AA (31%) versus CA (13%). AA exhibited a greater proportion of high-grade or type 2 papillary RCC (40% and 30%) versus CA (25% and 13%). CONCLUSIONS: AA patients were treated at a younger age, with a larger proportion of women. Postoperatively, AA experienced a greater increase in serum creatinine. Final histology demonstrated greater papillary RCC incidence in AA and increased likelihood for type 2 papillary RCC, a more aggressive histology.

Accelerometer Measurement of Head Movement During Laparoscopic Surgery as a Tool to Evaluate Skill Development of Surgeons.

OBJECTIVE: To detect and measure surgeons' head movement during laparoscopic simulator performance to determine whether expert surgeons have economy of motion in their head movement, including change of direction, compared with intermediate and novice surgeons. We investigated head movement as an objective tool for assessment of laparoscopic surgical skill and its potential use for assessing novice surgeons' progress on the learning curve. DESIGN: After obtaining institutional review board approval, medical students, urology residents, and attending staff surgeons from an academic institution were recruited. Participants were grouped by level of experience and performed tasks on the Electronic Data Generation for Evaluation laparoscopic simulator. Surgeons wore a commercially available wireless electroencephalogram monitor as a flexible, adjustable, and lightweight headband with 7 sensors-2 forehead sensors, 2 ear sensors, and 3 reference sensors. The headband incorporates a 3-axis accelerometer enabling head movement quantification. A variance analysis was used to compare the average head movement acceleration data between each group. SETTING: Tulane University Medical Center, New Orleans, LA, an academic medical center and the principal teaching hospital for Tulane University School of Medicine. PARTICIPANTS: A total of following 19 participants were recruited for the study and stratified by surgical experience into novice (n = 6), intermediate (n = 9), and expert (n = 4) laparoscopy groups: 6 medical students, 9 urology residents (postgraduate years 1 to5), and 4 attending urologists, respectively. RESULTS: Analysis of the average acceleration rate of head movement showed statistically significant differences among groups on both the vertical axis (p = 0.006) and horizontal axis (p = 0.018) in the laparoscopic suturing task. This demonstrated the ability to distinguish between experts and novice laparoscopic surgeons. The average acceleration among groups did not demonstrate statistical significance on the vertical axis (p = 0.078) and horizontal axis (p = 0.077) in the peg transfer task. This may be in response to the ease of the task. The analysis of the forward-backward axis or depth perception also showed no significant differences between groups. CONCLUSION: Accelerometer-based motion analysis of head movement appears to be a useful tool to evaluate laparoscopic skill development of surgeons in terms of their economy of motion, and it could potentially be used for ergonomic assessment of training in the future, and progression on the learning curve.

Electroencephalographic Monitoring of Brain Wave Activity During Laparoscopic Surgical Simulation to Measure Surgeon Concentration and Stress: Can the Student Become the Master?

PURPOSE: To measure gamma and alpha brain wave activity as a measurement of concentration and stress levels during surgical simulator performance of laparoscopic tasks to determine if expert surgeons have different brain activity patterns compared with intermediate and novice surgeons. MATERIALS AND METHODS: After obtaining Institutional Review Board approval, 1st and 2nd year medical students, urology residents (PGY2-PGY5), and attending urologists from one institution were recruited. Participants were stratified by level of experience and performed laparoscopic tasks on the EDGE laparoscopic simulator. Subjects were evaluated for concentration and stress levels using the electroencephalography (EEG) data extracted from the MUSE(™) headband. The MUSE software developer kit (SDK) allowed quantification of gamma and alpha waves during each task. An analysis of variance was used to compare concentration and stress levels between groups. RESULTS: A total of 19 participants were recruited for the study and stratified by surgical experience into novice, intermediate, and expert laparoscopy groups: 6 medical students, 9 urology residents, and 4 attending urologists, respectively. Concentration and stress were quantified by calculating the area under the curve of the gamma and alpha EEG wave tracings. Stress was significantly lower in the attending urologists compared with the residents and medical students during the laparoscopic suturing and trended toward significance in the peg transfer task (P = 0.0003, P = 0.069). Concentration was significantly higher in the expert group compared with the less experienced groups during both the peg and suture tasks (P = 0.036, P = 0.0039). CONCLUSIONS: EEG brain activity in more experienced surgeons reveals a significant increase in concentration levels with a decrease in stress during simulated laparoscopic tasks compared with novices. This information may correlate with increased proficiency as well as provide objective feedback of progress along the learning curve with the MUSE SDK.

Laparoscopic Radical Cystoprostatectomy, Surgical Technique and Result: A Case Report.

OBJECTIVE: Laparoscopic radical cystoprostatectomy is a complicated operation. The objective of this study is to present our technique and results of laparoscopic radical cystoprostatectomy. MATERIAL AND METHOD: A 72-year-old Thai male presented with gross hematuria. Cystoscope was performed. Large bladder tumor near right ureteric orifice was observed. Then, transurethral resection of bladder tumor was performed. His tumor pathology was muscle invasive high grade urothelial carcinoma with clinical staging T2N0M0. Laparoscopic radical cystoprostatectomy was then conducted with bilateral pelvic nodes dissection and ileal conduit. RESULTS: Operation period was eight hours. Blood loss was 500 ml. In pathological results, tumor invaded bladder muscle into perivesical tissue. Tumor margin was free. Lymph nodes were positive for malignancy 5/7 for right side and 0/4 for left side. Pathological staging was T3aN1M0. After post-operative period, the patient was discharged from hospital uneventfully. CONCLUSION: Laparoscopic radical cystoprostatectomy in Maha Chakri Sirindhorn Medical Center is minimal invasive, feasible and safe. However, a longer follow-up period regarding long-term cancer control as well as functional and technical aspects will be required.

Predicting factors for biochemical recurrence and oncological outcomes following laparoscopic radical prostatectomy in Rajavithi Hospital, Thailand.

OBJECTIVE: To determine the predicting factor of biochemical recurrence and analysis of pathological and oncological outcomes following laparoscopic radical prostatectomy (LRP) at Rajavithi Hospital in Thailand. MATERIAL AND METHOD: One hundred twenty men underwent laparoscopic radical prostatectomy between October 2006 and December 2011. Four men were excluded due to open surgical conversions and fourteen men were excluded due to lacking of follow-up. The remaining 102 men had a mean preoperative prostate specific antigen of 21.4 ng/ml (ranging from 0.4 to 185) and Gleason score of 6.2 (ranging from 6 to 10). Stage was cT1b in one case (1%), cT1c in 66 (64.7%), cT2 in 28 (27. 5%), and cT3 in seven (6.9%). Immediate postoperative adjuvant therapy of twenty-six men was excluded from biochemical recurrence analysis. RESULTS: Mean follow-up period was 19.7 months (median 16, ranging from 2 to 54.8). Pathological stage was pT0N0 in two men (2%), pT2N0 in 78 (76.5%), pT3N0 in 11 (10.8%), and pT2-3N1 in 11 (10.8%). Positive surgical margin (SM) rates increased with higher stage (23.1% in pT2, 63.6% in pT3 and 81.8% in pT2-3N1, p < 0.0001). Three-year biochemical recurrence-free survival was 87.1% for pT2N0 and 50% for pT3N0/N1 disease (p = 0.025), and 84.2% overall. Univariate analysis for age, preoperative PSA, postoperative Gleason score, pathological stage, and margin status showed that only margin status could be used as a predictor for biochemical recurrence. CONCLUSION: Predicting factor for biochemical recurrence after LRP was positive SM status. From the oncological result, LRP in our experience is a safe and efficacious therapy for localized prostate cancer with acceptable and was consistent with results of previous studies.