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1.
Int Braz J Urol ; 45(6): 1122-1128, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31808399

RESUMO

INTRODUCTION: To evaluate the influence of previous experience as bedside assistants on patient selection, perioperative and pathological results in robot assisted laparoscopic radical prostatectomy. MATERIALS AND METHODS: The first 50 cases of two robotic surgeons were reviewed retrospectively. Group 1 consisted of the first 50 cases of the surgeon with previous experience as a robotic bedside assistant between September 2016-July 2018, while group 2 included the first 50 cases of the surgeon with no bedside assistant experience between February 2009-December 2009. Groups were examined in terms of demographics, prostate volume, presence of median lobe, prostate specific antigen (PSA), preoperative Gleason score, positive core number, clinical stage, console surgery time, estimated blood loss, postoperative Gleason score, pathological stage, positive surgical margin rate, postoperative complications, length of hospital stay and biochemical recurrence rate. RESULTS: Previous abdominal surgery and the presence of median lobe hypertrophy rates were higher in Group 1 than in Group 2 (20% vs. 4%, p=0.014; 24% vs. 6%, p=0.012; respectively). In addition, patients in Group 1 were in a higher clinical stage than those in Group 2 (cT2: 70% vs. 28%, p=0.001). Median console surgery time and median length of hospital stay was significantly shorter in Group 1 than in Group 2 (170 min vs. 240 min, p=0.001; 3 vs. 4, p=0.022; respectively). Clavien grade 3 complication rate was higher in Group 2 but was statistically insignificant. CONCLUSION: Our findings might reflect that previous bedside assistant experience led to an increase in self-confidence and the ability to manage troubleshooting and made it more likely for surgeons to start with more difficult cases with more challenging patients. It is recommended that novice surgeons serve as bedside assistants before moving on to consoles.


Assuntos
Competência Clínica , Prostatectomia/educação , Procedimentos Cirúrgicos Robóticos/educação , Idoso , Humanos , Curva de Aprendizado , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Gradação de Tumores , Duração da Cirurgia , Prostatectomia/métodos , Neoplasias da Próstata/patologia , Neoplasias da Próstata/cirurgia , Estudos Retrospectivos , Procedimentos Cirúrgicos Robóticos/métodos , Autoimagem , Estatísticas não Paramétricas , Fatores de Tempo , Resultado do Tratamento
2.
Urology ; 132: 43-48, 2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-31228477

RESUMO

OBJECTIVE: To evaluate the impact of resident involvement in robot assisted laparoscopic prostatectomy on oncologic, functional, and intraoperative outcomes, both short and long term. METHODS: We queried our prospectively maintained database of prostate cancer patients who underwent robotic-assisted laparoscopic prostatectomy from November 20, 2007 to December 27, 2016. We analyzed cases performed by 1 surgeon on a specific day of the week when the morning case involved at least 1 resident (R) and the afternoon case involved the attending physician only (nonresident [NR]). We compared R versus NR on a number of clinical, perioperative, and oncological outcomes. RESULTS: A total of 230 NR and 230 R cases met inclusion criteria and were included in the analysis. Over one third (36.7%) of the NR group was Gleason 4+3 (Grade Group 3) or higher, relative to 25.9% of the R group, P = .015. Median operative time (OT) was significantly longer for R versus NR (200 minutes versus 156 minutes, P<.001) as was robotic time (161 minutes versus119 minutes, P<.001). No significant differences were noted for any other measure. Median follow-up for oncological outcomes was 30 and 33.5 months for NR and R, respectively (P= .3). Median OT and median estimated blood loss were both significantly greater in later years relative to the earlier years for R (2012-2016 versus 2007-2011; P< .001 for OT; P= .041 for median estimated blood loss) but not for NR. CONCLUSION: Neither safety nor quality is diminished by R involvement in robot assisted laparoscopic prostatectomy.


Assuntos
Internato e Residência , Laparoscopia , Prostatectomia/educação , Prostatectomia/métodos , Procedimentos Cirúrgicos Robóticos , Urologia/educação , Idoso , Humanos , Período Intraoperatório , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/epidemiologia , Recuperação de Função Fisiológica , Estudos Retrospectivos , Fatores de Tempo , Resultado do Tratamento
3.
Arch. esp. urol. (Ed. impr.) ; 72(3): 239-246, abr. 2019. graf
Artigo em Espanhol | IBECS | ID: ibc-180458

RESUMO

Objetivo: La Prostatectomía Radical asistida por Robot (PRAR) ha generado una nueva tendencia en el binomio enseñanza/aprendizaje agrupando estas técnicas en módulos de entrenamiento como aprendizaje teórico, practico, asesoramiento personalizado y herramientas modernas como simulación y práctica en modelos virtuales. Esta revisión resume la tendencia actual en el proceso de enseñanza de la PRAR. Hallazgos recientes: La tendencia actual en la adquisición de la curva de la PRAR es proporcionar al urólogo un proceso de enseñanza bien estructurado, implementando módulos de entrenamiento graduales, que le permitan comprender en todos los aspectos el desenvolvimiento de la cirugía radical de próstata con un sistema robótico. Dicho proceso consiste en analizar las bases teóricas, realizar entrenamiento con simulado res de alta calidad, interactuar con él supervisor tanto en casos in vivo como en ayudantía de cirugías, hasta completar la fase avanzada en consola con entrenamiento háptico y asesoramiento directo del supervisor, mientras se adquiere la curva de aprendizaje. La evidencia demuestra que la retroalimentación del alumno y proctor supervisor con el uso de modelos virtuales, análisis de videos inmediatamente posterior al procedimiento y un centro de alto volumen logran acortar el proceso de enseñanza. La formación en cirugía robótica nunca culmina, por el contrario, la fase final del alumno, es cuando se encuentra preparado para realizar el efecto multiplicador de su curva de aprendizaje. Conclusión: La Cirugía Robótica ha cambiado la perspectiva de la enseñanza de la Medicina, mediante el uso de modelos virtuales. Conocimientos teóricos, entrenamiento virtual y el asesoramiento del supervisor son pasos necesarios en la curva de aprendizaje. Direcciones futuras esperadas son la evolución de los modelos virtuales similares al escenario real


Objective of the review: Robot assisted Radical prostatectomy (RARP) has generated a new trend in the binomial teaching/learning, grouping these techniques in training modules such as theoretical learning, practice, personalized counseling, and modern tools like simulation and practice in virtual models. This review summarizes the current trend in the teaching process of RARP. Recent findings: Current trends in the acquisition of the RARP learning curve is to provide the Urologist with a well-structured teaching process, implementing gradual training modules, which make possible to understand all aspects of the development of prostate surgery with a robotic system. This process consists in analyzing the theoretical aspects, perform training with high quality simulators and proctorization, in both cases in vivo and as assistant, until completion of the advanced phase in console with haptic training and proctor’s direct advice, while the learning curve is being completed. The evidence shows that student and proctor feedback with the use of virtual models, immediately post-procedure video analysis, and a high-volume center are able to shorten the teaching process. The learning process never culminates, in other words, the final phase of the student, is when he is prepared to teaching the multiplier effect of his learning curve. Conclusions: Virtual models in Robotic surgery has changed the perspective teaching process of medicine. Theoretical knowledge, virtual training and Proctor’s advice are essential steps in the learning curve. Future directions, evolution of virtual models in a similar fashion to the real scenario


Assuntos
Humanos , Masculino , Prostatectomia/educação , Prostatectomia/métodos , Laparoscopia/métodos , Procedimentos Cirúrgicos Robóticos/educação , Educação Médica
4.
Khirurgiia (Mosk) ; (1): 89-94, 2019.
Artigo em Russo | MEDLINE | ID: mdl-30789615

RESUMO

Robotic surgery is a future method of minimal invasive surgery. Robot-assisted radical prostatectomy (RARP) is a common method of surgical treatment of prostate cancer. Due to significant differences of the surgical technique of RARP compared to open or laparoscopic radical prostatectomy (LRP) new methods of training are needed. At the moment there are many opinions how to train physicians best. Which model is the most effective one remains nowadays controversial. OBJECTIVE: Analyze currently available data of training methods of RARP. Determine the most effective training model and evaluate its advantages and disadvantages. Establish a standardized plan and criteria for proper training and certification of the entire surgical team. MATERIAL AND METHODS: Literature review based on PubMed database, Web of Science and Scopus by keywords: robot-assisted radical prostatectomy, training of robot-assisted prostatectomy, training in robot-assisted operations, a learning curve of robot-assisted prostatectomy, virtual reality simulators (VR-simulators) in surgery. RESULTS: According to the literature in average 18 to 45 procedures are required for a surgeon to achieve the plateau of the learning curve of the RARP. Parallel training, pre-operative warm-up and the use of virtual reality simulators (VR-simulators) can significantly increase the learning curve. There are many described models of RARP training. CONCLUSIONS: The absence of accepted criteria of evaluation of the learning curve does not allow to use this parameter as a guide for the surgeon's experience. Proper training of robotic surgeons is necessary and requires new methods of training. There are different types of training programs. In our opinion the most effective training program is when a surgeon observes the performance of tasks or any steps of operation on the VR-simulator, then he performs them and analyzes mistakes by video recording. Then the surgeon observes real operations and performs some steps of the operation which are already leant on the simulator under supervision of the mentor and analyzes mistakes by video recording. Thus, mastering first the simple stages under supervision of a mentor, the surgeon effectively adopts the surgical experience from him. It is necessary to train not only the surgeons but also the entire surgical team.


Assuntos
Prostatectomia/educação , Neoplasias da Próstata/cirurgia , Procedimentos Cirúrgicos Robóticos/educação , Simulação por Computador , Educação/normas , Humanos , Curva de Aprendizado , Masculino , Procedimentos Cirúrgicos Minimamente Invasivos/educação , Procedimentos Cirúrgicos Minimamente Invasivos/instrumentação , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Modelos Educacionais , Equipe de Assistência ao Paciente/normas , Prostatectomia/instrumentação , Prostatectomia/métodos , Procedimentos Cirúrgicos Robóticos/instrumentação , Procedimentos Cirúrgicos Robóticos/métodos , Realidade Virtual
5.
J Urol ; 202(1): 108-113, 2019 07.
Artigo em Inglês | MEDLINE | ID: mdl-30747873

RESUMO

PURPOSE: Improved cancer control with increasing surgical experience (the learning curve) has been demonstrated for open and laparoscopic prostatectomy. We assessed the relationship between surgical experience and oncologic outcomes of robot-assisted radical prostatectomy. MATERIALS AND METHODS: We analyzed the records of 1,827 patients in whom prostate cancer was treated with robot-assisted radical prostatectomy. Surgical experience was coded as the total number of robotic prostatectomies performed by the surgeon before the patient operation. We evaluated the relationship of prior surgeon experience to the probability of positive margins and biochemical recurrence in regression models adjusting for stage, grade and prostate specific antigen. RESULTS: After adjusting for case mix, greater surgeon experience was associated with a lower probability of positive surgical margins (p = 0.035). The risk of positive margins decreased from 16.7% to 9.6% in patients treated by a surgeon with 10 and 250 prior procedures, respectively (risk difference 7.1%, 95% CI 1.7-12.2). In patients with nonorgan confined disease the predicted probability of positive margins was 38.4% in those treated by surgeons with 10 prior operations and 24.9% in those treated by surgeons with 250 prior operations (absolute risk reduction 13.5%, 95% CI -3.4-22.5). The relationship between surgical experience and the risk of biochemical recurrence after surgery was not significant (p = 0.8). CONCLUSIONS: Specific techniques used by experienced surgeons which are associated with improved margin rates need further research. The impact of experience on cancer control after robotic prostatectomy differed from that in the prior literature on open and laparoscopic radical prostatectomy, and should be investigated in larger multi-institutional studies.


Assuntos
Laparoscopia/estatística & dados numéricos , Curva de Aprendizado , Margens de Excisão , Recidiva Local de Neoplasia/epidemiologia , Prostatectomia/estatística & dados numéricos , Neoplasias da Próstata/cirurgia , Procedimentos Cirúrgicos Robóticos/estatística & dados numéricos , Competência Clínica/estatística & dados numéricos , Humanos , Laparoscopia/educação , Laparoscopia/métodos , Masculino , Recidiva Local de Neoplasia/prevenção & controle , Próstata/patologia , Próstata/cirurgia , Prostatectomia/educação , Prostatectomia/métodos , Neoplasias da Próstata/patologia , Procedimentos Cirúrgicos Robóticos/educação , Procedimentos Cirúrgicos Robóticos/métodos , Cirurgiões/educação , Cirurgiões/estatística & dados numéricos , Resultado do Tratamento
6.
Urology ; 125: 34-39, 2019 03.
Artigo em Inglês | MEDLINE | ID: mdl-30615893

RESUMO

OBJECTIVE: To evaluate the opinion of Holmium laser enucleation of the prostate (HoLEP)-naïve urologists about a surgical simulator and the level of difficulty at each step. MATERIALS AND METHODS: We evaluated 40 HoLEP-naïve urologists in a course involving 4 steps: lecture introducing Holmium laser basics and technique; live surgery; video explaining prostate enucleation using simulators; and simulator trial. A survey was applied to evaluate content validity and face validity of the simulator. Subjects also ranked the level of difficulty of each surgical step. RESULTS: All urologists agreed on the importance of a validated HoLEP simulator in training; 95% agreed that simulation-based training is essential for patient safety. The mean rate of face validity of all analyzed components was 8.4 (8.1-9.0). Instrumentation was considered the most realistic component, followed by laser-tissue interaction. Positioning the fiber and bladder neck incisions (BNIs) at 5 and 7-o'clock were the easiest steps. Detaching the median lobe from the bladder neck, BNI at 12, dividing the mucosal bridge distally, and joining the upper and lower incisions were the most difficult steps. Residents found more difficulty in joining the BNIs distally (3.6 vs 2.4, P = .006) and in dividing the mucosal bridge distally (4.0 vs 3.0, P = .038) when compared to specialists. CONCLUSION: HoLEP-naïve urologists found this simulator useful and important for patient safety. Most components were considered realistic. Simulation was able to reproduce the levels of difficulty usually found in real life cases. The level of expertise may influence the learning process of some steps.


Assuntos
Atitude do Pessoal de Saúde , Lasers de Estado Sólido/uso terapêutico , Prostatectomia/educação , Prostatectomia/métodos , Treinamento por Simulação , Urologia/educação , Adulto , Idoso , Humanos , Pessoa de Meia-Idade , Estudos Prospectivos
7.
Urology ; 123: 293-294, 2019 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-30312672

RESUMO

OBJECTIVE: To present a simplified technique for GreenLight laser enucleation of the prostate (GreenLEP), designed to reduce the learning curve commonly associated with endoscopic prostate enucleation. MATERIALS AND METHODS: GreenLEP is a novel endoscopic treatment for BPH which allows for durable resection of large glands with minimal energy use, minimal bleeding and has been shown to be non-inferior to holmium laser enucleation of the prostate (HoLEP). Furthermore, GreenLEP has been shown to be superior to GreenLight PVP For glands >80 g with respect to operative time, unplanned hospital readmission and decrease in post treatment PSA and prostate size. Unfortunately, a steep learning curve has remained a roadblock for adaptation by many urologists. Our technique for lobe-by-lobe GreenLEP is described and shown. RESULTS: GreenLEP allows for removal of the entire transition zone in patients with large glands traditionally best treated with staged TURP or simple prostatectomy. A lobe-by-lobe approach allows the urologist to learn the procedure in a stepwise fashion as they become increasingly comfortable with the technique. During the learning process, some lobes may be addressed by enucleation while others by vaporization. CONCLUSION: This simplified technique allows novice enucleators with GreenLight experience to feel more comfortable with GreenLEP, simplifying the learning curve.


Assuntos
Terapia a Laser , Prostatectomia/métodos , Hiperplasia Prostática/cirurgia , Humanos , Terapia a Laser/métodos , Curva de Aprendizado , Masculino , Próstata , Prostatectomia/educação
8.
Ann Surg ; 269(1): 79-82, 2019 01.
Artigo em Inglês | MEDLINE | ID: mdl-29064892

RESUMO

OBJECTIVE: To describe a novel, outcome-based method of standard setting that differentiates between clinical outcomes rather than arbitrary educational goals. BACKGROUND: Standard setting methods used in assessments of procedural skill are currently not evidence-driven or outcome-based. This represents a potential obstacle for the broad implementation of these evaluations in summative assessments such as certification and credentialing. METHODS: The concept is based on deriving a receiver operating characteristic curve from a regression model that incorporates measures of intraoperative surgeon performance and confounding patient characteristics. This allows the creation of a performance standard that best predicts a clinically significant outcome of interest. The discovery cohort used to create the predictive model was derived from pilot data that used the Global Evaluative Assessment of Robotic Skill assessment tool to predict patient urinary continence 3 months following robotic-assisted radical prostatectomy. RESULTS: A receiver operating characteristic curve with an area under the curve of 0.75 was created from predicted probability statistic generated by the predictive model. We chose a predicted probability of 0.35, based on an optimal tradeoff in sensitivity and specificity (Youden Index). Rearranging the regression equation, we determined the performance score required to predict a 35%, patient-adjusted probability of postoperative urinary incontinence. CONCLUSIONS: This novel methodology is context, patient, and assessment-specific. Current standard setting methods do not account for the heterogeneity of the clinical environment. Workplace-based assessments in competency-based medical education require standards that are credible to the educator and the trainee. High-stakes assessments must ensure that surgeons have been evaluated to a standard that prioritizes satisfactory patient outcomes and safety.


Assuntos
Competência Clínica/normas , Medidas de Resultados Relatados pelo Paciente , Próstata/cirurgia , Prostatectomia/educação , Procedimentos Cirúrgicos Robóticos/educação , Cirurgiões/educação , Incontinência Urinária/epidemiologia , Seguimentos , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Ontário/epidemiologia , Complicações Pós-Operatórias/epidemiologia , Prostatectomia/métodos , Estudos Retrospectivos
9.
World J Urol ; 37(5): 799-804, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-30191394

RESUMO

PURPOSE: With the rapidly expanding anatomical and technical knowledge surrounding nervesparing radical prostatectomy (NSRP), anatomical and operative textbooks have failed to keep pace with the literature. A surgical skill laboratory (SSL) was designed to educate urology trainees on surgical anatomy and techniques for NSRP. The objective was to assess the validity of a SSL program. METHODS: A low-fidelity, anatomically accurate prostate model with its appropriate fascial coverings and location of the neurovascular bundle was created. Participants were surveyed prior to a SSL workshop for their knowledge of NSRP focusing on clinical and anatomical considerations. An interactive 2-h tutorial and workshop was then undertaken outlining the clinical and anatomical nuances for NSRP, with participants then practising an intra and inter-fascial NSRP on the model. Participants were resurveyed immediately after the workshop and at 6 months. RESULTS: Thirty participants completed the NSRP workshop. Significant differences (p < 0.0001) in anatomical and clinical knowledge were noted after the workshop with improvements for both junior and senior trainees. The knowledge was retained at 6 months following the workshop. CONCLUSIONS: A low-fidelity bench-top model is a feasible and reproducible technique for improving the understanding of periprostatic anatomy and the different surgical approaches for NSRP. The SSL is useful and knowledge gained appears to be retained by workshop participants. SSL workshops are a valid hands-on approach to teaching surgical skills and should remain an integral part of urology training.


Assuntos
Prostatectomia/educação , Neoplasias da Próstata/cirurgia , Urologia/educação , Competência Clínica , Educação , Humanos , Masculino , Tratamentos com Preservação do Órgão , Nervos Periféricos/anatomia & histologia , Próstata/anatomia & histologia , Próstata/cirurgia , Prostatectomia/métodos , Treinamento por Simulação
10.
Sex Med Rev ; 7(2): 293-305, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-30057140

RESUMO

INTRODUCTION: Men undergoing prostatectomy can have unrealistic preoperative expectations regarding sexual function after surgery and may desire more education on recovery and symptom management. AIM: To present contemporary data on recovery of sexual function after prostatectomy and characterize how it is impacted by perioperative patient educational interventions. METHODS: A comprehensive review of the English-language literature available by PubMed search. MAIN OUTCOME MEASURES: Rates of sexual function recovery after prostatectomy and the impact of educational interventions on these and related outcomes. RESULTS: Available studies describe heterogeneous educational and support interventions that differ by patient selection, content, method of delivery, timing, and duration. Interventions with group-based education or peer support benefitted sexual satisfaction metrics. Many studies included men and their partners in supportive interventions. However, the few randomized controlled trials directly analyzing the effect of partner attendance revealed no additional benefit to outcomes. Interventions within 6 weeks of prostatectomy variably aided measures of sexual recovery. Some studies with greater time between prostate cancer treatment and interventions revealed only temporary improvements in outcomes. Yet durable improvements in sexual satisfaction and sexual function were observed in some men enrolled years after prostate cancer treatment. At times, web-based interventions had lower completion rates, but sexual function outcomes were comparable to traditional in-person interventions within randomized trials. CONCLUSION: Educational interventions imparted variable benefit to sexual function and satisfaction, with group-based designs mostly benefitting satisfaction outcomes. Despite standardized interventions, men reported worse-than-expected outcomes, suggesting an emphasis on counseling regarding changes in erectile function at multiple time points before surgery and during the recovery period may be helpful. Earlier interventions may help with recovery by establishing more accurate patient expectations. Regarding accessibility, future endeavors may be improved with internet-based educational content, as such interventions appeared to provide comparable benefits to in-person sessions. Faris AER, Montague DK, Gill BC. Perioperative Educational Interventions and Contemporary Sexual Function Outcomes of Radical Prostatectomy. Sex Med Rev 2019;7:293-305.


Assuntos
Educação em Saúde , Período Perioperatório , Prostatectomia/efeitos adversos , Recuperação de Função Fisiológica , Sexo , Humanos , Masculino , Satisfação Pessoal , Prostatectomia/educação , Disfunções Sexuais Fisiológicas/etiologia , Resultado do Tratamento
11.
Int Braz J Urol ; 45(1): 54-60, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30521164

RESUMO

INTRODUCTION: The success of the robot assisted radical prostatectomy (RARP) procedures depend on a successful team, however the literature focuses on the performance of a console surgeon. The aim of this study was to evaluate surgical outcomes of the surgeons during the learning curve in relation to the bedside assistant's experience level during RARP. MATERIALS AND METHODS: We retrospectively reviewed two non - laparoscopic, beginner robotic surgeon's cases, and we divided the patients into two groups. The first surgeon completed the operations on 20 patients with a beginner bedside assistant in February - May 2009 (Group-1). The second surgeon completed operations on 16 patients with an experienced (at least 150 cases) bedside assistant in February 2015 - December 2015 (Group-2). The collected data included age, prostate volume, prostate specific antigen (PSA), estimated blood loss, complications and percent of positive surgical margins. In addition, the elapsed time for trocar insertion, robot docking, console surgery, specimen extraction and total anesthesia time were measured separately. RESULTS: There were no significant differences between the groups in terms of age, co-morbidity, prostate volume, PSA value, preoperative Gleason score, number of positive cores, postoperative Gleason score, pathological grade, protection rate of neurovascular bundles, surgical margin positivity, postoperative complications, length of hospital stay, or estimated blood loss. The robot docking, trocar placement, console surgery, anesthesia and specimen extraction times were significantly shorter in group 2 than they were in group 1 (17.75 ± 3.53 min vs. 30.20 ± 7.54 min, p ≤ 0.001; 9.63 ± 2.71 min vs. 14.40 ± 4.52 min , p = 0.001; 189.06 ± 27.70 min vs. 244.95 ± 80.58 min, p = 0.01; 230.94 ± 30.83 min vs. 306.75 ± 87.96 min, p = 0.002; 10.19 ± 2.54 min vs. 17.55 ± 8.79 min, p = 0.002; respectively). CONCLUSION: Although the bedside assistant's experience in RARP does not appear to influence the robotic surgeon's oncological outcomes during the learning curve, it may reduce the potential complications by shortening the total operation time.


Assuntos
Competência Clínica , Curva de Aprendizado , Prostatectomia/educação , Neoplasias da Próstata/cirurgia , Procedimentos Cirúrgicos Robóticos/métodos , Humanos , Masculino , Pessoa de Meia-Idade , Gradação de Tumores , Estadiamento de Neoplasias , Duração da Cirurgia , Antígeno Prostático Específico , Prostatectomia/métodos , Estudos Retrospectivos , Procedimentos Cirúrgicos Robóticos/educação , Resultado do Tratamento
12.
Medicine (Baltimore) ; 97(51): e13569, 2018 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-30572458

RESUMO

BACKGROUND: To compare the superiority of teaching methods for acquiring a proficient level of surgical skill in a robotic surgery-naïve individual using a robotic virtual reality simulator. METHODS: This study employed a prospective, randomized study design to assess student's learning curve. We divided 45 subjects into 3 groups: those with expert proctoring (group I), those who watched only an educational video (group II), and those with independent training (group III; n = 15 per group). The task used in this study was the Tube 2 and it imitates a vesicourethral anastomosis in robotic prostatectomy. The effects were analyzed by the time to end the task after overcoming the learning curve which is determined by several performance parameters. RESULTS: The number of task repetitions required to reach the learning curve plateau was 45, 42, and 37 repetitions in groups I, II, and III, which means that there was continuous improvement in performing the task after 40 repetitions only in groups I and II. The mean time for completing the task during the stabilization period was significantly different between group I and group III and group II and group III, which means that the independent training method was inferior to the other methods (group I vs. group II vs. group III: 187.38 vs. 187.07 vs. 253.47 seconds, P < .001). CONCLUSIONS: This study's findings showed that an educational video can be as beneficial as expert proctoring, which implies that the development of a standardized educational video would be worthwhile.


Assuntos
Educação de Pós-Graduação em Medicina/métodos , Filmes Cinematográficos , Procedimentos Cirúrgicos Robóticos/educação , Treinamento por Simulação , Cirurgiões , Realidade Virtual , Adulto , Competência Clínica , Docentes de Medicina , Feminino , Humanos , Curva de Aprendizado , Masculino , Prostatectomia/educação , Prostatectomia/métodos , Robótica , Treinamento por Simulação/métodos , Estudantes de Medicina , Cirurgiões/educação
13.
J Endourol ; 32(11): 1071-1077, 2018 11.
Artigo em Inglês | MEDLINE | ID: mdl-30226409

RESUMO

PURPOSE: To assess the extent to which surgical experience can affect perioperative and functional outcomes after photoselective vaporization of the prostate (PVP) with 180W XPX GreenLight laser in patients with lower urinary tract symptoms secondary to benign prostatic obstruction (BPO). MATERIALS AND METHODS: Data from 291 consecutive patients with symptomatic BPO (median follow-up 12 m) were collected and analyzed. Patients were treated at 2 different institutions by 2 expert (G1, n = 182) and 2 novice (G2, n = 109) transurethral prostate surgeons (February 2013 - March 2017) and underwent standard or anatomical PVP depending on surgeons' preferences. Patients' characteristics, perioperative and functional outcomes were compared using the chi-square and Mann-Whitney U tests. Patients' satisfaction was measured using the Patient Global Impression of Improvement (PGI-I) score. Learning curves were analyzed based on changes in quantitative parameters: surgery time, lasing/operative time, and energy delivered (kJ). RESULTS: Patients' baseline characteristics, perioperative data and PGI-I score were similar. Overall the complication rates showed better trends for G1. Serum prostate-specific antigen levels, maximum flow rate, and International Prostatic Symptoms Score improved in both groups, with perceived improvements greater in G2 (p < 0.006). Lasing time/operative time ratio showed greater evolution for G1 than G2 (0.50:IQR 0.38-0.60 vs 0.46:IQR 0.34-0.58, respectively)(p = 0.201). A major increase in energy delivery for G2 was achieved within the first 50 procedures, whereas more than 100 iterations were needed for G1 to reach LT/OT >60%. CONCLUSION: Surgeons' background and expertise appear to affect outcomes over the learning curve, with roughly similar perioperative and functional results.


Assuntos
Competência Clínica , Curva de Aprendizado , Prostatectomia/educação , Hiperplasia Prostática/cirurgia , Idoso , Humanos , Itália , Lasers de Estado Sólido , Masculino , Pessoa de Meia-Idade , Duração da Cirurgia , Satisfação do Paciente , Complicações Pós-Operatórias , Prostatectomia/métodos , Resultado do Tratamento , Volatilização
14.
J Endourol ; 32(11): 1021-1027, 2018 11.
Artigo em Inglês | MEDLINE | ID: mdl-30064256

RESUMO

OBJECTIVES: Literature regarding experience with three-dimensional (3D) laparoscopy in urology has remained scanty, and this might be also related to the parallel explosion of robot-assisted laparoscopic surgery. The study aim was to compare 3D vs two-dimensional (2D) laparoscopic approaches for urological procedures in perioperative outcomes in a subgroups analysis of studies reporting procedures requiring intracorporeal suturing. MATERIALS AND METHODS: We searched EMBASE and Medline from database inception to September 22, 2017 for studies comparing patients undergoing 2D vs 3D laparoscopic approach for urological procedures. Two investigators independently selected studies for inclusion. Studies identification and selection was performed according to PRISMA criteria. Quality of the studies was assessed by the Newcastle-Ottawa and the Jadad scales for nonrandomized controlled trials (RCTs) and RCTs, respectively. For continuous variables, weighted mean difference was used for quantitative synthesis; for categorical variables, the odds ratio with confidence interval (95% CI) was used instead. A random-effect model was used for pooled estimates to account for heterogeneity. Statistical analyses were performed using RevMan 5.3 (Cochrane Collaboration, Oxford, United Kingdom). RESULTS: Eight comparative studies of interest published in English were found and considered for the quantitative synthesis. Among them, four were RCTs. Six studies regarded procedures requiring intracorporeal suturing and were considered for cumulative-analysis. Meta-analysis did not show any significant difference in operative time. Quantitative synthesis showed advantages for 3D laparoscopy in terms of operative time, blood losses, and length of stay. When limited to studies regarding radical prostatectomy, operative time significantly favored 3D approach (mean difference -35.00, 95% CI -41.34 to -28.67 minutes). CONCLUSIONS: The present systematic review and cumulative-analysis indicated that 3D laparoscopy could offer some advantages in terms of operative time for more challenging procedures requiring intracorporeal suture.


Assuntos
Competência Clínica , Laparoscopia/educação , Prostatectomia/educação , Procedimentos Cirúrgicos Urológicos/educação , Humanos , Imagem Tridimensional
15.
Urology ; 122: 32-36, 2018 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-30144481

RESUMO

OBJECTIVE: To predict actual performance in real surgery when vesicourethral anastomosis (VUA) is performed in patients after Tube 3 module training of robot-naive surgeons. METHODS: Forty-five patients were enrolled and divided into 3 groups according to chronological trends (each containing 15 patients). Three robot-naive surgeons in a single center completed VUA in robot-assisted radical prostatectomy (RARP) following robotic virtual reality simulator (RVRS) training. The practicing tool used in robotic virtual reality simulator was Tube 3, which was invented for the dV-Trainer that imitates a VUA in RARP. The effects of performance were investigated by analyzing the number of repetitions and the time required to complete the task until achieving the predetermined proficiency level. RESULTS: The targeted time (predetermined proficiency level) for completing tasks of Tube 3 and the number of required task repetitions to achieve the proficiency level were 283.1 s and 36 times, respectively, whereas in actual VUA procedures, the number of required attempts was 24, with an average time of 14.9 minutes. The mean time for completing VUA in real surgery significantly decreased with serial cases among all surgeons (1-15 vs 16-30 vs 31-45 cases, P <.001), as well as comparisons between groups (P <.001). CONCLUSION: The Tube 3 module can represent a valuable educational tool for procedure-specific robotic training by bridging the gap between safe acquisition of surgical skills and effective performance during actual VUA in RARP.


Assuntos
Educação de Pós-Graduação em Medicina/métodos , Prostatectomia/educação , Procedimentos Cirúrgicos Robóticos/educação , Cirurgiões/educação , Urologia/educação , Realidade Virtual , Adulto , Anastomose Cirúrgica/educação , Competência Clínica , Simulação por Computador , Estudos de Viabilidade , Humanos , Curva de Aprendizado , Masculino , Prostatectomia/métodos , Procedimentos Cirúrgicos Robóticos/métodos , Treinamento por Simulação , Ureter/cirurgia , Bexiga Urinária/cirurgia
16.
J Urol ; 200(4): 895-902, 2018 10.
Artigo em Inglês | MEDLINE | ID: mdl-29792882

RESUMO

PURPOSE: We sought to develop and validate automated performance metrics to measure surgeon performance of vesicourethral anastomosis during robotic assisted radical prostatectomy. Furthermore, we sought to methodically develop a standardized training tutorial for robotic vesicourethral anastomosis. MATERIALS AND METHODS: We captured automated performance metrics for motion tracking and system events data, and synchronized surgical video during robotic assisted radical prostatectomy. Nonautomated performance metrics were manually annotated by video review. Automated and nonautomated performance metrics were compared between experts with 100 or more console cases and novices with fewer than 100 cases. Needle driving gestures were classified and compared. We then applied task deconstruction, cognitive task analysis and Delphi methodology to develop a standardized robotic vesicourethral anastomosis tutorial. RESULTS: We analyzed 70 vesicourethral anastomoses with a total of 1,745 stitches. For automated performance metrics experts outperformed novices in completion time (p <0.01), EndoWrist® articulation (p <0.03), instrument movement efficiency (p <0.02) and camera manipulation (p <0.01). For nonautomated performance metrics experts had more optimal needle to needle driver positioning, fewer needle driving attempts, a more optimal needle entry angle and less tissue trauma (each p <0.01). We identified 14 common robotic needle driving gestures. Random gestures were associated with lower efficiency (p <0.01), more attempts (p <0.04) and more trauma (p <0.01). The finalized tutorial contained 66 statements and figures. Consensus among 8 expert surgeons was achieved after 2 rounds, including among 58 (88%) after round 1 and 8 (12%) after round 2. CONCLUSIONS: Automated performance metrics can distinguish surgeon expertise during vesicourethral anastomosis. The expert vesicourethral anastomosis technique was associated with more efficient movement and less tissue trauma. Standardizing robotic vesicourethral anastomosis and using a methodically developed tutorial may help improve robotic surgical training.


Assuntos
Competência Clínica/normas , Prostatectomia/normas , Procedimentos Cirúrgicos Robóticos/normas , Cirurgiões/educação , Urologia/normas , Anastomose Cirúrgica/educação , Anastomose Cirúrgica/métodos , Anastomose Cirúrgica/normas , Anastomose Cirúrgica/estatística & dados numéricos , Competência Clínica/estatística & dados numéricos , Consenso , Humanos , Masculino , Duração da Cirurgia , Prostatectomia/educação , Prostatectomia/métodos , Prostatectomia/estatística & dados numéricos , Procedimentos Cirúrgicos Robóticos/educação , Procedimentos Cirúrgicos Robóticos/métodos , Procedimentos Cirúrgicos Robóticos/estatística & dados numéricos , Cirurgiões/normas , Cirurgiões/estatística & dados numéricos , Fatores de Tempo , Uretra/cirurgia , Bexiga Urinária/cirurgia , Urologia/educação
17.
Arch Ital Urol Androl ; 90(1): 1-7, 2018 Mar 31.
Artigo em Inglês | MEDLINE | ID: mdl-29633788

RESUMO

AIM: The success of Robot Assisted Laparoscopic Prostatectomy (RALP) is mainly due to his relatively short learning curve. Twenty cases are needed to reach a "4 hours-proficiency". However, to achieve optimal functional outcomes such as urinary continence and potency recovery may require more experience. We aim to report the perioperative and early functional outcomes of patients undergoing RALP, after a structured modular training program. METHODS: A surgeon with no previous laparoscopic or robotic experience attained a 3 month modular training including: a) e-learning; b) assistance and training to the operating table; c) dry console training; d) step by step in vivo modular training performing 40 surgical steps in increasing difficulty, under the supervision of an experienced mentor. Demographics, intraoperative and postoperative functional outcomes were recorded after his first 120 procedures, considering four groups of 30 cases. RESULTS: All procedures were completed successfully without conversion to open approach. Overall 19 (15%) post operative complications were observed and 84% were graded as minor (Clavien I-II). Overall operative time and console time gradually decreased during the learning curve, with statistical significance in favour of Group 4. The overall continence rate at 1 and 3 months was 74% and 87% respectively with a significant improvement in continence rate throughout the four groups (p = 0.04). Considering those patients submitted to nerve-sparing procedure we found a significant increase in potency recovery over the four groups (p = 0.04) with the higher potency recovery rate up to 80% in the last 30 cases. CONCLUSIONS: Optimal perioperative and functional outcomes have been attained since early phase of the learning curve after an intensive structured modular training and less than 100 consecutive procedures seem needed in order to achieve optimal urinary continence and erectile function recovery.


Assuntos
Curva de Aprendizado , Prostatectomia/educação , Procedimentos Cirúrgicos Robóticos/educação , Procedimentos Cirúrgicos Urológicos/educação , Idoso , Disfunção Erétil/epidemiologia , Disfunção Erétil/etiologia , Seguimentos , Humanos , Incidência , Laparoscopia/educação , Masculino , Mentores , Pessoa de Meia-Idade , Duração da Cirurgia , Complicações Pós-Operatórias/epidemiologia , Neoplasias da Próstata/cirurgia , Resultado do Tratamento , Incontinência Urinária/epidemiologia , Incontinência Urinária/etiologia
18.
J Surg Educ ; 75(3): 758-766, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-28974429

RESUMO

OBJECTIVE: To perform the first validation of a full procedural virtual reality robotic training module and analysis of novice surgeon's learning curves. DESIGN: Participants completed the bladder neck dissection task and urethrovesical anastomosis task (UVA) as part of the prostatectomy module. Surgeons completed feedback questionnaires assessing the realism, content, acceptability and feasibility of the module. Novice surgeons completed a 5.5-hour training programme using both tasks. SETTING: King's College London, London. PARTICIPANTS: 13 novice, 24 intermediate and 8 expert surgeons completed the validation study. RESULTS: Realism was scored highly for BDN (mean 3.4/5) and UVA (3.74/5), as was importance of BDN (4.32/5) and UVA (4.6/5) for training. It was rated as a feasible (3.95/5) and acceptable (4/5) tool for training. Experts performed significantly better than novice group in 6 metrics in the UVA including time (p = 0.0005), distance by camera (p = 0.0010) and instrument collisions (p = 0.0033), as well as task-specific metrics such as number of unnecessary needle piercing points (p = 0.0463). In novice surgeons, a significant improvement in performance after training was seen in many metrics for both tasks. For bladder neck dissection task, this included time (p < 0.0001), instrument collisions (p = 0.0013) and total time instruments are out of view (p = 0.0251). For UVA, this included time (p = 0.0135), instrument collisions (p = 0.0066) and task-specific metrics such as injury to the urethra (p = 0.0032) and bladder (p = 0.0189). CONCLUSIONS: Surgeons found this full procedural VR training module to be a realistic, feasible and acceptable component for a robotic surgical training programme. Construct validity was proven between expert and novice surgeons. Novice surgeons have shown a significant learning curve over 5.5 hours of training, suggesting this module could be used in a surgical curriculum for acquisition of technical skills. Further implementation of this module into the curriculum and continued analysis would be beneficial to gauge how it can be fully utilised.


Assuntos
Competência Clínica , Educação de Pós-Graduação em Medicina/métodos , Prostatectomia/educação , Procedimentos Cirúrgicos Robóticos/educação , Realidade Virtual , Adulto , Simulação por Computador , Feminino , Humanos , Curva de Aprendizado , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Reino Unido , Adulto Jovem
19.
World J Urol ; 36(2): 171-175, 2018 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-29124346

RESUMO

PURPOSE: Live surgery (LS) is considered a useful teaching opportunity. The benefits must be balanced with patient safety concerns. To evaluate the rate of complications of a series of urologic LS performed by experts during the Congress Challenge in Laparoscopy and Robotics (CILR). METHODS: We present a large, multi-institution, multi-surgeon database that derives from 12 CILR events, from 2004 to 2015 with a total of 224 cases. Radical prostatectomy (RP) was the most common procedure and a selection of complex cases was noted. The primary measure was postoperative complications and use of a Postoperative Morbidity Index (PMI) to allow quantitative weighing of postoperative complications. RESULTS: From 12 events, the number of cases increased from 11 in 2004 to 27 in 2015 and a total of 27 surgeons. Of 224 cases (164 laparoscopic and 60 robotic), there were 26 (11.6%) complications: 5 grade I, 5 grade II, 3 grade IIIa, 12 grade IIIb and 1 grade V, the latter from laparoscopic cystectomy. Analysis of PMI was 23 times higher from cystectomy compared to RP. CONCLUSIONS: In the setting of live surgery, the overall rate of complications is low considering the complexity of surgeries. The PMI is not higher in more complex procedures, whereas RP seems very safe.


Assuntos
Laparoscopia/educação , Complicações Pós-Operatórias/epidemiologia , Procedimentos Cirúrgicos Robóticos/educação , Procedimentos Cirúrgicos Urológicos/educação , Estudos de Coortes , Cistectomia/educação , Feminino , Humanos , Excisão de Linfonodo/educação , Masculino , Nefrectomia/educação , Prostatectomia/educação , Estudos Retrospectivos , Índice de Gravidade de Doença
20.
J Urol ; 199(1): 296-304, 2018 01.
Artigo em Inglês | MEDLINE | ID: mdl-28765067

RESUMO

PURPOSE: We explore and validate objective surgeon performance metrics using a novel recorder ("dVLogger") to directly capture surgeon manipulations on the da Vinci® Surgical System. We present the initial construct and concurrent validation study of objective metrics during preselected steps of robot-assisted radical prostatectomy. MATERIALS AND METHODS: Kinematic and events data were recorded for expert (100 or more cases) and novice (less than 100 cases) surgeons performing bladder mobilization, seminal vesicle dissection, anterior vesicourethral anastomosis and right pelvic lymphadenectomy. Expert/novice metrics were compared using mixed effect statistical modeling (construct validation). Expert reviewers blindly rated seminal vesicle dissection and anterior vesicourethral anastomosis using GEARS (Global Evaluative Assessment of Robotic Skills). Intraclass correlation measured inter-rater variability. Objective metrics were correlated to corresponding GEARS metrics using Spearman's test (concurrent validation). RESULTS: The performance of 10 experts (mean 810 cases, range 100 to 2,000) and 10 novices (mean 35 cases, range 5 to 80) was evaluated in 100 robot-assisted radical prostatectomy cases. For construct validation the experts completed operative steps faster (p <0.001) with less instrument travel distance (p <0.01), less aggregate instrument idle time (p <0.001), shorter camera path length (p <0.001) and more frequent camera movements (p <0.03). Experts had a greater ratio of dominant-to-nondominant instrument path distance for all steps (p <0.04) except anterior vesicourethral anastomosis. For concurrent validation the median experience of 3 expert reviewers was 300 cases (range 200 to 500). Intraclass correlation among reviewers was 0.6-0.7. For anterior vesicourethral anastomosis and seminal vesicle dissection, kinematic metrics had low associations with GEARS metrics. CONCLUSIONS: Objective metrics revealed experts to be more efficient and directed during preselected steps of robot-assisted radical prostatectomy. Objective metrics had limited associations to GEARS. These findings lay the foundation for developing standardized metrics for surgeon training and assessment.


Assuntos
Competência Clínica/normas , Prostatectomia/normas , Neoplasias da Próstata/cirurgia , Procedimentos Cirúrgicos Robóticos/normas , Cirurgiões/normas , Adulto , Humanos , Curva de Aprendizado , Excisão de Linfonodo/educação , Excisão de Linfonodo/normas , Masculino , Pessoa de Meia-Idade , Projetos Piloto , Prostatectomia/educação , Procedimentos Cirúrgicos Robóticos/educação , Cirurgiões/educação , Análise e Desempenho de Tarefas
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