Safe transition from extracorporeal to intracorporeal urinary diversion following robot-assisted cystectomy: a recipe for reducing operative time, blood loss and complication rates

OBJECTIVEPosterior-based thoracolumbar 3-column osteotomy (3CO) is a formidable surgical procedure. Surgeon experience and case volume are known factors that influence surgical complication rates, but these factors have not been studied well in cases of adult spinal deformity (ASD). This study examines how surgeon experience affects perioperative complications and operative measures following thoracolumbar 3CO in ASD.METHODSA retrospective study was performed of a consecutive cohort of thoracolumbar ASD patients who underwent 3CO performed by the senior authors from 2006 to 2018. Multivariate analysis was used to assess whether experience (years of experience and/or number of procedures) is associated with perioperative complications, operative duration, and blood loss.RESULTSA total of 362 patients underwent 66 vertebral column resections (VCRs) and 296 pedicle subtraction osteotomies (PSOs). The overall complication rate was 29.4%, and the surgical complication rate was 8.0%. The rate of postoperative neurological deficits was 6.2%. There was a trend toward lower overall complication rates with greater operative years of experience (from 44.4% to 28.0%) (p = 0.115). Years of operative experience was associated with a significantly lower rate of neurological deficits (p = 0.027); the incidence dropped from 22.2% to 4.0%. The mean operative time was 310.7 minutes overall. Both increased years of experience and higher case numbers were significantly associated with shorter operative times (p < 0.001 and p = 0.001, respectively). Only operative years of experience was independently associated with operative times (p < 0.001): 358.3 minutes from 2006 to 2008 to 275.5 minutes in 2018 (82.8 minutes shorter). Over time, there was less deviation and more consistency in operative times, despite the implementation of various interventions to promote fusion and prevent construct failure: utilization of multiple-rod constructs (standard, satellite, and nested rods), bone morphogenetic protein, vertebroplasty, and ligament augmentation. Of note, the use of tranexamic acid did not significantly lower blood loss.CONCLUSIONSSurgeon years of experience, rather than number of 3COs performed, was a significant factor in mitigating neurological complications and improving quality measures following thoracolumbar 3CO for ASD. The 3- to 5-year experience mark was when the senior surgeon overcame a learning curve and was able to minimize neurological complication rates. There was a continuous decrease in operative time as the surgeon’s experience increased; this was in concurrence with the implementation of additional preventative surgical interventions. Ongoing practice changes should be implemented and can be done safely, but it is imperative to self-assess the risks and benefits of those practice changes.

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Outcomes of Intracorporeal Urinary Diversion after Robot-Assisted Radical Cystectomy: Results from the International Robotic Cystectomy Consortium

The Journal of Urology ◽

10.1016/j.juro.2017.12.045 ◽

2018 ◽

Vol 199 (5) ◽

pp. 1302-1311 ◽

Cited By ~ 58

Author(s):

Ahmed A. Hussein ◽

Paul R. May ◽

Zhe Jing ◽

Youssef E. Ahmed ◽

Carl J. Wijburg ◽

...

Keyword(s):

Radical Cystectomy ◽

Urinary Diversion ◽

Robot Assisted ◽

Robotic Cystectomy ◽

Intracorporeal Urinary Diversion

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Impact of body mass index on robot-assisted radical cystectomy with intracorporeal urinary diversion

BJU International ◽

10.1111/bju.13916 ◽

2017 ◽

Vol 120 (5) ◽

pp. 689-694 ◽

Cited By ~ 7

Author(s):

Nariman Ahmadi ◽

Thomas G. Clifford ◽

Gus Miranda ◽

Jie Cai ◽

Monish Aron ◽

...

Keyword(s):

Body Mass Index ◽

Radical Cystectomy ◽

Urinary Diversion ◽

Body Mass ◽

Robot Assisted ◽

Intracorporeal Urinary Diversion

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Surgery-related Complications of Robot-assisted Radical Cystectomy With Intracorporeal Urinary Diversion

Urology ◽

10.1016/j.urology.2010.11.035 ◽

2011 ◽

Vol 77 (4) ◽

pp. 871-876 ◽

Cited By ~ 48

Author(s):

Martin C. Schumacher ◽

Martin N. Jonsson ◽

Abolfazl Hosseini ◽

Tommy Nyberg ◽

Vassilis Poulakis ◽

...

Keyword(s):

Radical Cystectomy ◽

Urinary Diversion ◽

Robot Assisted ◽

Intracorporeal Urinary Diversion

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STANDARD OPEN MICRODISCECTOMY VERSUS MINIMAL ACCESS TROCAR MICRODISCECTOMY

Neurosurgery ◽

10.1227/01.neu.0000311075.56486.c5 ◽

2008 ◽

Vol 62 (1) ◽

pp. 174-182 ◽

Cited By ~ 71

Author(s):

Yu-Mi Ryang ◽

Markus F. Oertel ◽

Lothar Mayfrank ◽

Joachim M. Gilsbach ◽

Veit Rohde

Keyword(s):

Blood Loss ◽

Visual Analog Scale ◽

Oswestry Disability Index ◽

Operative Time ◽

Short Form ◽

Lumbar Disc ◽

Complication Rates ◽

Minimal Access ◽

Analog Scale ◽

Short Form 36

Abstract OBJECTIVE Minimal access surgery as a less invasive alternative to standard macro- and microsurgical approaches is becoming increasingly popular in the management of traumatic and degenerative spine diseases. However, data is lacking if minimal access spine surgery is indeed beneficial. This prospective randomized study was conducted to compare efficiency, safety, and outcome of standard open microsurgical discectomy (SOMD) for lumbar disc herniation with microsurgical discectomy using an 11.5 mm trocar system for minimal access to the spine. METHODS Sixty patients were randomized to two groups of 30 patients each. Group 1 was treated by SOMD, and Group 2 was treated by minimal access microsurgical discectomy (MAMD). Perioperative parameters and pre- and postoperative clinical findings including sensory or motor deficits and pain according to the visual analog scale, Oswestry Disability Index scores, and Short Form-36 results were assessed. All patients were followed for at least 6 months postoperatively (mean, 16 mo). RESULTS Preoperatively, no statistically significant intergroup differences could be detected proving the comparability of both groups. Postoperatively, significant improvement of neurological symptoms and pain as measured by the visual analog scale, Oswestry Disability Index, and Short Form-36 scores could be achieved in both groups. In regard to operative time, intraoperative blood loss, and complication rate, slightly better results were observed in the MAMD group. CONCLUSION SOMD and MAMD allow achievement of significant improvement of pain and neurological deficits in patients with lumbar disc herniations. Differences in operative time, blood loss, and complication rates were statistically not significant in MAMD compared with SOMD, indicating that, at least in lumbar disc surgery, minimal access trocar techniques are a viable alternative to standard spinal approaches.

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