Trainees Do Not Negatively Impact the Institutional Learning Curve for Robotic Prostatectomy as Characterized by Operative Time, Estimated Blood Loss, and Positive Surgical Margin Rate

Objective. Analyze the learning curve for laparoscopic radical prostatectomy in a low volume program.Materials and Methods. A single surgeon operated on 165 patients. Patients were consecutively divided in 3 groups of 55 patients (groups A, B, and C). An enhancement of estimated blood loss, surgery length, and presence of a positive surgical margin were all considered as a function of surgeon’s experience.Results. Operative time was 267 minutes for group A, 230 minutes for group B, and 159 minutes for group C, and the operative time decreased over time, but a significant difference was present only between groups A and C (). Mean estimated blood loss was 328 mL, 254 mL, and 206 mL (). A conversion to open surgery was necessary in 4 patients in group A. Positive surgical margin rates were 29.1%, 21.8%, and 5.5% (). Eight patients in group A, 4 patients in group B, and one in group C had biochemical recurrence.Conclusion. Significantly less intraoperative complications were evident after the first 51 cases. All other parameters (blood loss, operative time, and positive surgical margins) significantly decreased and stabilized after 110 cases. Those outcomes were somehow similar to previous published series by high-volume centers.

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The role of bedside assistant during robot assisted radical prostatectomy: Is more experience better? Analysis on perioperative and clinical outcomes

Urologia Journal ◽

10.1177/0391560320951085 ◽

2020 ◽

pp. 039156032095108

Author(s):

Mario Salvatore Mangano ◽

Claudio Lamon ◽

Francesco Beniamin ◽

Alberto De Gobbi ◽

Matteo Ciaccia ◽

...

Keyword(s):

Radical Prostatectomy ◽

Blood Loss ◽

Clinical Outcomes ◽

Operative Time ◽

Surgical Margin ◽

Positive Surgical Margin ◽

Robot Assisted ◽

Estimated Blood Loss ◽

Bedside Assistant ◽

The Impact

Objectives: To analyze the impact of the bedside assistant’s experience during RARP. It is believed that the outcome of robotic surgery during Robot Assisted Radical Prostatectomy (RARP) for prostate cancer depends not only on the console surgeon’s experience. Materials and Methods: All consecutive RARPs from January 2017 to March 2018 were sourced from a prospectively maintained database. All cases were performed by the same surgeon. He was supported by three bedside assistants: one with bedside and console experience, one only with relevant bedside experience, one basically inexperienced. The patient’s parameters analyzed: age, Body Mass Index (BMI), previous abdominal surgery, prostate volume (by TRUS), pre-operative PSA, bioptic grading. Surgical outcomes analyzed included skin-to-skin operative time and estimated blood loss; clinical outcomes included length of hospital stay and time to catheter removal; the oncological outcome was represented by positive surgical margin rate. Results: A total of 116 RARPs were identified: 38 RARPs were performed with the console experienced bedside assistant, 38 with the experienced one, 40 with the novice one. The variables were similar between the three groups. As far as outcomes are concerned, there were no statistically significant differences between the three bedside assistants in terms of operative time, estimated blood loss, length of stay, days of catheterization, positive surgical margin rate.

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Positive surgical margin rates during the robot-assisted laparoscopic radical prostatectomy learning curve of an experienced laparoscopic surgeon

Canadian Urological Association Journal ◽

10.5489/cuaj.4588 ◽

2017 ◽

Vol 11 (11) ◽

pp. E409-13 ◽

Cited By ~ 2

Author(s):

Anthony F. Adili ◽

Julia Di Giovanni ◽

Emma Kolesar ◽

Nathan C. Wong ◽

Jen Hoogenes ◽

...

Keyword(s):

Radical Prostatectomy ◽

Learning Curve ◽

Surgical Margin ◽

Margin Status ◽

Laparoscopic Radical Prostatectomy ◽

Positive Surgical Margin ◽

Robot Assisted ◽

Estimated Blood Loss ◽

The Mean ◽

The Impact

Introduction: Since its introduction, robot-assisted laparoscopic radical prostatectomy (RARP) has gained widespread popularity, but is associated with a variable learning curve. Herein, we report the positive surgical margin (PSM) rates during the RARP learning curve of a single surgeon with significant previous laparoscopic radical prostatectomy (LRP) experience.Methods: We performed a prospective cohort study of the first 400 men with prostate cancer treated with RARP by a single surgeon (BS) with significant LRP experience. Our primary outcome was the impact of case timing in the learning curve on margin status. Our analysis was conducted by dividing the case numbers into quartiles (Q1‒Q4) and determining if a case falling into an earlier quartile had an impact on margin status relative to the most recent quartile (Q4).Results: The Q1 cases had an odds ratio for margin positivity of 1.74 compared to Q4 (p=0.1). Multivariate logistic regression did not demonstrate case number to be a significant predictor of PSM. The mean Q1 operative time was 207.4 minutes, decreasing to 179.2 by Q4 (p<0.0001). The mean Q1 estimated blood loss was 255.1 ml, decreasing to 213.6 by Q4 (p=0.0064). There was no change in length of hospitalization within the study period.Conclusions: Even when controlling for copredictors, a statistically significant learning curve for PSM rate of a surgeon with significant previous LRP experience was not detected during the first 400 RARP cases. We hypothesize that previous LRP experience may reduce the RARP PSM learning curve.

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Reconstruction of the ligamentous apparatus of the lower pelvis in robot-assisted radical prostatectomy as a stage of the learning curve

Andrology and Genital Surgery ◽

10.17650/1726-9784-2021-22-1-76-84 ◽

2021 ◽

Vol 22 (1) ◽

pp. 76-84

Author(s):

Ya. A. Svetocheva ◽

R. I. Slusarenko ◽

D. G. Tsarichenko ◽

R. B. Suhanov ◽

E. A. Bezrukov ◽

...

Keyword(s):

Radical Prostatectomy ◽

Blood Loss ◽

Learning Curve ◽

Patient Group ◽

Surgical Margin ◽

Positive Surgical Margin ◽

Robot Assisted ◽

Early Recovery ◽

Surgical Time ◽

Urine Retention

Objective of the study. To evaluate results of robot-assisted laparoscopic radical prostatectomy in the framework of a surgeon’s learning curve; to evaluate the effect of reconstruction of the ligamentous apparatus of the lower pelvis on early recovery of urine retention.Materials and methods. 246 patients were divided into 3 groups depending on the surgery date. The analyzed data was accumulated prospectively and retrospectively. Preoperative characteristics (TNM stage, PSA, ISUP), intraoperative characteristics (surgical time, blood loss volume, surgery type and character, type of reconstruction of the ligamentous apparatus of the lower pelvis) and postoperative characteristics (duration of bladder drainage with a urethral catheter, level and time of recovery for urine retention and erectile function) were evaluated. Reconstruction of the ligamentous apparatus of the lower pelvis was performed through reconstruction of the Denonvillier fascia (Rocco stitch), as well as through suturing fibers of the bladder neck with periurethral tissues and residual puboprostatic ligaments for stabilization of the urethrovesical complex.Results. All operations were successfully completed without conversions or transfusions. Median surgical time was 160 minutes (p = 0.0001). Median blood loss was 173.3 cm3 (p = 0.0002). Mean prostatic volume was 36 cm3 (29–47.5 cm3), and overall frequency of positive surgical margin was 12.82 %. Overall frequency of urine retention recovery was 51.6 % after 3 months, 63.7 % after 6 months (p >0.05). In the patient group with reconstruction of the ligamentous apparatus of the lower pelvis, frequency of urine retention recovery was higher than in the group without reconstruction: 64.1 % vs 45.3 % (after 3 months, р = 0.041) and 74.7 % vs 62.3 % (after 6 months, р = 0.034). Conclusion. Surgical time, blood loss were significantly decreased with the number of performed operative interventions. Significant improvement of early urine retention recovery was observed in the patient group with reconstruction of the ligamentous apparatus of the lower pelvis.

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Learning curve for laparoscopic Roux-en-Y gastric bypass based on the experience of a newly created bariatric center

Polish Journal of Surgery ◽

10.5604/01.3001.0014.1513 ◽

2020 ◽

Vol 92 (4) ◽

pp. 23-30

Author(s):

Jadwiga Dworak ◽

Michał Wysocki ◽

Anna Rzepa ◽

Michał Pędziwiatr ◽

Dorota Radkowiak ◽

...

Keyword(s):

Morbid Obesity ◽

Gastric Bypass ◽

Adverse Events ◽

Learning Curve ◽

Operative Time ◽

Perioperative Complications ◽

Safe Procedure ◽

Experienced Surgeon ◽

Institutional Learning ◽

Complications And Mortality

ntroduction: Laparoscopic Roux-en-Y gastric bypass (LRYGB) is one of the most common treatments for morbid obesity. The learning curve for this procedure is 50–75 cases for an independent surgeon, and it is considered the most important factor in decreasing complications and mortality. We present our experience and learning curve with LRYGB for a newly established bariatric center in Poland. Material and methods: A prospectively collected database containing 285 LRYGB procedures performed in the II Department of General Surgery of the Jagiellonian University MC in Krakow between 06.2010 and 03.2019 was retrospectively reviewed. Patients were divided into groups of 30 (G1–G10) in the order of the procedures performed by each surgeon. The study analyzed the course of the operation and patient hospitalization, comparing those groups. Learning curve for the newly created bariatric center was established. Results: Operative time in G1–G3 differed significantly from G4–G10 (P < 0.0001). The stabilization point was the 90th procedure. Perioperative complications were observed in 36 (12.63%) patients. Perioperative complications, intraoperative difficulties and adverse events did not differ importantly among groups. Liberal use of “conversions of the operator” from a surgeon to a senior surgeon provides reasonable safety and prevents complications. Conclusions: The institutional learning process stabilization point for LRYGB in a newly established bariatric center is around the 90th operation. LRYGB can be a safe procedure from the very beginning in newly established bariatric centers. Specific bariatric training with active proctoring by an experienced surgeon in a bariatric centre can improve the laparoscopic gastric bypass outcome during the learning curve.

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Comparison of open and robotic-assisted prostatectomy: The University of British Columbia experience

Canadian Urological Association Journal ◽

10.5489/cuaj.1707 ◽

2014 ◽

Vol 8 (3-4) ◽

pp. 92 ◽

Cited By ~ 9

Author(s):

Louis-Olivier Gagnon ◽

Larry Goldenberg ◽

Kenny Lynch ◽

Antonio Hurtado ◽

Martin Gleave

Keyword(s):

Urinary Incontinence ◽

Length Of Stay ◽

Learning Curve ◽

Tertiary Care ◽

Surgical Margin ◽

Hospital Length Of Stay ◽

Positive Surgical Margin ◽

Robotic Assisted ◽

Post Surgery ◽

The Impact

Introduction: We assessed outcomes and costs of open prostatectomy (OP) versus robotic-assisted prostatectomy (RAP) at a single tertiary care university hospital.Methods: We retrospectively analyzed 200 consecutive OP by 1 experienced open surgeon (MG) and 200 consecutive RAP by an experienced open surgeon (SLG), after allowing for a short learning curve of 70 cases.Results: The 2 groups had similar demographics, including mean age (64.7 vs. 64.2) and mean body mass index (27.2 vs. 27.2). The OP group had a higher proportion of higher risk cancers compared to the RAP group (32.5% vs. 8.5%). Mean skin-to-skin operative room time was less for the OP (114.2 vs. 234.1 minutes). Transfusion rates were similar at 1.5% with OP compared to 3.5% with RAP. The mean length of stay was 1.78 days for OP compared to 1.76 days for RAP, for the last 100 patients in each group. The OP group had more high-grade disease in the prostatectomy specimen, with Gleason ≥8 in 23.5% compared to 3.5% in the RAP group. Positive surgical margin rates were comparable at 31% for OP and 24.6% for RAP, and remained similar after stratification for pT2 and pT3 disease. The grade I and II perioperative complication rate (Clavien-Dindo classification) was lower in the OP group (8.5% vs. 20%). Postoperative stress urinary incontinence rates (4.8% for OP and 4.6% for RAP) and biochemical-free status (91.8% for OP and 96% for RAP) did not differ at 12 months post-surgery. The additional cost of RAP was calculated as $5629 per case. The main limitations of this study are its retrospective nature and lack of validated questionnaires for evaluation of postoperative functional outcomes.Conclusion: While hospital length of stay, transfusion rates, positive surgical margin rates and postoperative urinary incontinence were similar, OP had a shorter operative time and a lower cost compared to the very early experience of RAP. Future parallel prospective analysis will address the impact of the learning curve on these outcomes.

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A team approach to anterior lumbar spine surgery in the military

Vascular ◽

10.1177/1708538113478757 ◽

2013 ◽

Vol 22 (4) ◽

pp. 246-251 ◽

Cited By ~ 3

Author(s):

Anahita Dua ◽

Jennifer Fox ◽

Bhavin Patel ◽

Eric Martin ◽

Michael Rosner ◽

...

Keyword(s):

Lumbar Spine ◽

Blood Loss ◽

Operative Time ◽

Lumbar Spine Surgery ◽

Team Approach ◽

Disc Space ◽

Estimated Blood Loss ◽

All Cause Mortality ◽

The Military ◽

Median Operative Time

We report a five year military experience with anterior retroperitoneal spine exposure combining vascular and neurosurgical spine teams. From August 2005 through April 2010 (56 months), hospital records from a single institution were retrospectively reviewed. Complications, estimated blood loss, transfusions, operative time and length of stay were documented. Eighty-four patients with lumbar spondylosis underwent primary (63, 75%) or secondary exposure (21, 25%) of a single- (66, 79%) or multilevel disc space (18, 21%). Median operative time and estimated blood loss were 127 minutes (range, 30–331 minutes) and 350 mL (range, 0–2940 mL). The overall complication rate was 23.8%. Postoperative complications included six blood transfusions (7%), three patients with retrograde ejaculation (3.57%) or surgical site infection; two with a prolonged ileus (2.38%) or ventral hernia and one each with a bowel obstruction (1, 1.19%), deep venous thrombosis or lymphocele. All-cause mortality was 1%. In conclusion, a team approach can minimize complications while offering the technical benefits and durability of an anterior approach to the lumbar spine.

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Tourniquet Use in Wide-Awake Carpal Tunnel Release

Hand ◽

10.1177/1558944718787853 ◽

2018 ◽

Vol 15 (1) ◽

pp. 59-63 ◽

Cited By ~ 5

Author(s):

Sarah E. Sasor ◽

Julia A. Cook ◽

Stephen P. Duquette ◽

Elizabeth A. Lucich ◽

Adam C. Cohen ◽

...

Keyword(s):

Blood Loss ◽

Carpal Tunnel ◽

Local Anesthetic ◽

Operative Time ◽

Carpal Tunnel Release ◽

Estimated Blood Loss ◽

Tunnel Syndrome ◽

Clinically Significant ◽

Without Tourniquet ◽

Wide Awake

Background: Carpal tunnel syndrome is a common cause of upper extremity discomfort. Surgical release of the median nerve can be performed under general or local anesthetic, with or without a tourniquet. Wide-awake carpal tunnel release (CTR) (local anesthesia, no sedation) is gaining popularity. Tourniquet discomfort is a reported downside. This study reviews outcomes in wide-awake CTR and compares tourniquet versus no tourniquet use. Methods: Wide-awake, open CTRs performed from February 2013 to April 2016 were retrospectively reviewed. Patients were divided into 2 cohorts: with and without tourniquet. Demographics, comorbidities, tobacco use, operative time, estimated blood loss, complications and outcomes were compared. Results: A total of 304 CTRs were performed on 246 patients. The majority of patients were male (88.5%), and the mean age was 59.9 years. One hundred patients (32.9%) were diabetic, and 92 patients (30.2%) were taking antithrombotics. Seventy-five patients (24.7%) were smokers. A forearm tourniquet was used for 90 CTRs (29.6%). Mean operative time was 24.97 minutes with a tourniquet and 21.69 minutes without. Estimated blood loss was 3.16 mL with a tourniquet and 4.25 mL without. All other analyzed outcomes were not statistically significant. Conclusion: Operative time was statistically longer and estimated blood loss was statistically less with tourniquet use, but these findings are not clinically significant. This suggests that local anesthetic with epinephrine is a safe and effective alternative to tourniquet use in CTR. The overall rate of complications was low, and there were no major differences in postoperative outcomes between groups.

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Radiofrequency bipolar coagulation for radical hysterectomy: Technique, feasibility and complications

International Journal of Gynecological Cancer ◽

10.1136/ijgc-00009577-200303000-00015 ◽

2003 ◽

Vol 13 (2) ◽

pp. 187-191

Author(s):

A. Ercoli ◽

A. Fagotti ◽

M. Malzoni ◽

G. Ferrandina ◽

T. Susini ◽

...

Keyword(s):

Blood Loss ◽

Radical Hysterectomy ◽

Operative Time ◽

Bipolar Coagulation ◽

Maximal Diameter ◽

Estimated Blood Loss ◽

Safe Technique ◽

Radiofrequency Coagulation ◽

Vessel Dissection

This study describes the surgical technique and intra- and postoperative complications associated with the use of a radiofrequency bipolar coagulator in a series of 18 Piver type III-IV radical hysterectomies performed in cervical cancer patients. Preliminary vessel-by-vessel dissection of the lateral parametria was possible in 17 out of 18 (94%) cases, and a direct application of a radiofrequency bipolar coagulation instrument was performed to coagulate the posterior and anterior parametrial tissues in all cases. We were able to easily coagulate isolated vessels up to 5 mm of maximal diameter. In no case were clamps or hemoclips necessary to complete hemostasis. We did not observe any parametrial vessel damage or heat-related injury of the surrounding normal tissue. The median size of the parametria removed was 44 mm (range 31–58) and nodes were detected in 15 cases (83%). Median operative time and estimated blood loss for the whole procedure including systematic pelvic and aortic lymphadenectomy was 250 min (range 200–410) and 550 ml (range 400–2500), respectively. Median follow-up time was 9 months (range 5–13). No complications specifically related to the use of radiofrequency coagulation were found. In conclusion the radio-frequency coagulation with this instrument appears to be a safe technique that is particularly useful in reducing blood loss and operative time without affecting radicality in patients undergoing radical hysterectomy.

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