The rapid uptake of robotic prostatectomy and its collateral effects

Lowrance, William T.; Parekh, Dipen J.

doi:10.1002/cncr.26275

Cited by 9 publications

(8 citation statements)

References 16 publications

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“…4 However, despite issues related to credentialing and training, there has been no standard RARP curriculum for trainees so far, even in the era of surgical simulators.…”

Section: Discussionmentioning

confidence: 99%

“…Since first described in 2001, robotic-assisted radical prostatectomy (RARP) has continued to gain widespread acceptance with less postoperative morbidity, reduced blood loss, along with some supportive data of improved early continence and erectile function recovery. [1][2][3] For these reasons, over 80% of radical prostatectomies are performed robotically in the United States, 4 as well as growing percentages globally. Moreover, acquisition of robotic skills is crucial in the early learning curve particularly for residents, fellows, and urologists already established in practice.…”

Section: Introductionmentioning

confidence: 99%

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Factors predicting prolonged operative time for individual surgical steps of robot-assisted radical prostatectomy (RARP): A single surgeon’s experience

Al‐Enizi

Valdivieso

Meskawi

et al. 2015

CUAJ

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Introduction: We evaluated the average time required to complete individual steps of robotic-assisted radical prostatectomy (RARP) by an expert RARP surgeon. The intent is to help establish a timebased benchmark to aim for during apprenticeship. In addition, we aimed to evaluate preoperative patient factors, which could prolong the operative time of these individual steps. Methods: We retrospectively identified 247 patients who underwent RARP, performed by an experienced robotic surgeon at our institution. Baseline patient characteristics and the duration of each step were recorded. Multivariate analysis was performed to predict factors of prolonged individual steps. Results: In multivariable analysis, obesity was a significant predictor of prolonged operative time of: docking (odds ratio [OR] 1.96), urethral division (OR 3.13), and vesico-urethral anastomosis (VUA) (OR 2.63). Prostate volume was also a significant predictor of longer operative time in dorsal vein complex ligation (OR 1.02), bladder neck division (OR 1.03), pedicle control (OR 1.04), urethral division (OR 1.02), and VUA (OR 1.03). A prolonged bladder neck division was predicted by the presence of a median lobe (OR 5.03). Only obesity (OR 2.56) and prostate volume (OR 1.04) were predictors of a longer overall operative time. Conclusions: Obesity and prostate volume are powerful predictors of longer overall operative time. Furthermore, both can predict prolonged time of several individual RARP steps. The presence of a median lobe is a strong predictor of a longer bladder neck division. These factors should be taken into consideration during RARP training. IntroductionThe introduction of the da Vinci robotic system (Intuitive Surgical, Inc.) has made a dramatic impact in the treatment of localized prostate cancer. Since first described in 2001, robotic-assisted radical prostatectomy (RARP) has continued to gain widespread acceptance with less postoperative morbidity, reduced blood loss, along with some supportive data of improved early continence and erectile function recovery.1-3 For these reasons, over 80% of radical prostatectomies are performed robotically in the United States, 4 as well as growing percentages globally. Moreover, acquisition of robotic skills is crucial in the early learning curve particularly for residents, fellows, and urologists already established in practice. However, lack of a standardized robotic training curriculum, coupled with reduced resident working hours, impose further difficulties in the mastering of robotic techniques during training.The learning curve of RARP is complex as well as its definition. When using a 4-hour case proficiency, Ahlering and colleagues reported a RARP learning curve of 12 cases for a laparoscopic-naïve surgeon.5 In a recent report by Al-Hathal and colleagues, the RARP learning curve of a fellowshiptrained surgeon was evaluated at 50 cases after which the positive surgical margin (PSM) rate in organ-confined disease was significantly reduced and the overall operative time (OT) was ...

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“…4 However, despite issues related to credentialing and training, there has been no standard RARP curriculum for trainees so far, even in the era of surgical simulators.…”

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Factors predicting prolonged operative time for individual surgical steps of robot-assisted radical prostatectomy (RARP): A single surgeon’s experience

Al‐Enizi

Valdivieso

Meskawi

et al. 2015

CUAJ

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“…About 69% to 85% of prostatectomies are performed robotically in the United States. 2 Although RARP has not been widely adopted in Canada, there is a growing pool of expertise and interest. There are presently 19 operational daVinci surgical systems (Intuitive Surgical Inc.) in Canada (personal communication via email, Daniel Minogue from Minogue Medical Inc., February 14, 2013).…”

Section: Introductionmentioning

confidence: 99%

Perioperative, oncological, and functional outcomes of the first robotic prostatectomy program in Quebec: Single fellowship-trained surgeon's experience of 250 cases

Alhathal

El-Hakim

2013

CUAJ

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Background: Robotic-assisted radical prostatectomy (RARP) is being increasingly done in Canada. Despite this, the Canadian literature lacks publications on the oncologic and functional outcomes of RARP. The objective of this study is to report the longest single surgeon experience in the province of Quebec. Methods: We collected prospective data from 250 consecutive patients who underwent RARP by a single fellowship trained surgeon (AEH) from October 2006 to October 2012. Mean followup was 28 months (range: 1-72). The D'Amico risk stratification distribution was 34% in low-risk, 48% in intermediate-risk and 18% in high-risk groups. Results: The mean operation time (±SD) was 194 ± 60.6 minutes, and estimated blood loss 318 ± 179 mL. The transfusion rate was only 0.4%. All procedures were completed robotically. The mean hospital stay was 1.2 days, and 88% of patients were discharged on postoperative day 1. The mean catheterization time was 7 days (range: 6-13). There were 2% major (Clavien III-IV) and 7.2% minor (Clavien I-II) postoperative complications, and no mortalities. On final pathology, 76% of patients were organ-confined and 70% specimen-confined. Pathological Gleason sum ≥7 accounted for 86%. Return of urinary continence (0-pads) at 3, 6, 12, and 24 months was 73.3%, 83.5%, 92.3%, 96.5%, respectively. Potency rate (successful penetration with or without medication) at 6, 12, and 24 months was 49.3%, 85%, and 95.3%, respectively. Operative time and positive surgical margin (PSM) in organ-confined disease (pT2) decreased significantly after 50 cases. Seventeen patients (6.8%) had no undetectable prostate-specific antigen (PSA) at first visit (PSA <0.1 ng/mL). Of remaining 233 patients, biochemical recurrence (PSA >0.2 ng/mL) was 4.7% (11 patients), and another 3.4% (8 patients) received early salvage radiotherapy (rising PSA, but <0.2 ng/mL). No patients with undetectable PSA required salvage treatments within 6 months postoperatively. Conclusions:Our results compare favourably with high-volume RARP programs, despite mainly intermediate-to high-risk disease. Initial learning curve was estimated to be 50 cases. Fellowship training was instrumental in achieving adequate functional and oncological outcomes, while maintaining low complications rate.

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“…The collateral effects of minimally invasive technology are controversial and are currently being debated. 3 The environmental collateral effects of minimally invasive surgery (MIS) have not been considered.…”

Section: Introductionmentioning

confidence: 99%

Environmental Impact of Minimally Invasive Surgery in the United States: An Estimate of the Carbon Dioxide Footprint

Power

Silberstein

Ghoneim

et al. 2012

Journal of Endourology

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Purpose: To attempt to quantitate the carbon footprint of minimally invasive surgery (MIS) through approximated scope 1 to 3 CO 2 emissions to identify its potential role in global warming. Patients and Methods: To estimate national usage, we determined the number of inpatient and outpatient MIS procedures using International Classification of Diseases, ninth revision-clinical modification codes for all MIS procedures in a 2009 sample collected in national databases. Need for surgery was considered essential, and therefore traditional open surgery was used as the comparator. Scope 1 (direct) CO 2 emissions resulting from CO 2 gas used for insufflation were based on both escaping procedural CO 2 and metabolic CO 2 eliminated via respiration. Scopes 2 and 3 (indirect) emissions related to capture, compression, and transportation of CO 2 to hospitals and the disposal of single-use equipment not used in open surgery were calculated. Results: The total CO 2 emissions were calculated to be 355,924 tonnes/year. For perspective, if MIS in the United States was considered a country, it would rank 189th on the United Nations 2008 list of countries' carbon emissions per year. Limitations include the inability to account for uncertainty using the various models and tools for approximating CO 2 emissions. Conclusion: CO 2 emission of MIS in the United States may have a significant environmental impact. This is the first attempt to quantify CO 2 emissions related to MIS in the United States. Strategies for reduction, while maintaining high quality medical care, should be considered.

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The rapid uptake of robotic prostatectomy and its collateral effects

Cited by 9 publications

References 16 publications

Factors predicting prolonged operative time for individual surgical steps of robot-assisted radical prostatectomy (RARP): A single surgeon’s experience

Factors predicting prolonged operative time for individual surgical steps of robot-assisted radical prostatectomy (RARP): A single surgeon’s experience

Perioperative, oncological, and functional outcomes of the first robotic prostatectomy program in Quebec: Single fellowship-trained surgeon's experience of 250 cases

Environmental Impact of Minimally Invasive Surgery in the United States: An Estimate of the Carbon Dioxide Footprint

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