Andrew P. Stegemann

Complications After Robot-assisted Radical Cystectomy: Results from the International Robotic Cystectomy Consortium

BACKGROUND Complication reporting is highly variable and nonstandardized. Therefore, it is imperative to determine the surgical outcomes of major oncologic procedures. OBJECTIVE To describe the complications after robot-assisted radical cystectomy (RARC) using a standardized and validated reporting methodology. DESIGN, SETTING, AND PARTICIPANTS Using the International Robotic Cystectomy Consortium (IRCC) database, we identified 939 patients who underwent RARC, had available complication data, and had at least 90 d of follow-up. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Complications were analyzed and graded according to the Memorial Sloan-Kettering Cancer Center (MSKCC) system and were defined and stratified by organ system. Secondary outcomes included identification of preoperative and intraoperative variables predicting complications. Logistic regression models were used to define predictors of complications and readmission. RESULTS AND LIMITATIONS Forty-one percent (n=387) and 48% (n=448) of patients experienced a complication within 30 and 90 d of surgery, respectively. The highest grade of complication was grade 0 in 52%, grade 1-2 in 29%, and grade 3-5 in 19% patients. Gastrointestinal, infectious, and genitourinary complications were most common (27%, 23%, and 17%, respectively). On multivariable analysis, increasing age group, neoadjuvant chemotherapy, and receipt of blood transfusion were independent predictors of any and high-grade complications, respectively. Thirty and 90-d mortality was 1.3% and 4.2%, respectively. As a multi-institutional database, a disparity in patient selection, operating standards, postoperative management, and reporting of complications can be considered a major limitation of the study. CONCLUSIONS Surgical morbidity after RARC is significant when reported using a standardized reporting methodology. The majority of complications are low grade. Strict reporting of complications is necessary to advocate for radical cystectomy (RC) and helps in patient counseling.

Fundamental Skills of Robotic Surgery: A Multi-institutional Randomized Controlled Trial for Validation of a Simulation-based Curriculum

OBJECTIVE To develop and establish effectiveness of simulation-based robotic curriculum--fundamental skills of robotic surgery (FSRS). METHODS FSRS curriculum was developed and incorporated into a virtual reality simulator, Robotic Surgical Simulator (RoSS). Fifty-three participants were randomized into an experimental group (EG) or control group (CG). The EG was asked to complete the FSRS and 1 final test on the da Vinci Surgical System (dVSS). The dVSS test consisted of 3 tasks: ball placement, suture pass, and fourth arm manipulation. The CG was directly tested on the dVSS then offered the chance to complete the FSRS and re-tested on the dVSS as a crossover (CO) group. RESULTS Sixty-five percent of participants had never formally trained using laparoscopic surgery. Ball placement: the EG demonstrated shorter time (142 vs 164 seconds, P = .134) and more precise (1.5 vs 2.5 drops, P = .014). The CO took less time (P <.001) with greater precision (P <.001). Instruments were rarely lost from the field. Suture pass: the EG demonstrated better camera utilization (4.3 vs 3.0, P = .078). Less instrument loss occurred (0.5 vs 1.1, P = .026). Proper camera usage significantly improved (P = .009). Fourth arm manipulation: the EG took less time (132 vs 157 seconds, P = .302). Meanwhile, loss of instruments was less frequent (0.2 vs 0.8, P = .076). Precision in the CO improved significantly (P = .042) and camera control and safe instrument manipulation showed improvement (1.5 vs 3.5, 0.2 vs 0.9, respectively). CONCLUSION FSRS curriculum is a valid, feasible, and structured curriculum that demonstrates its effectiveness by significant improvements in basic robotic surgery skills.

Defining Morbidity of Robot-Assisted Radical Cystectomy Using a Standardized Reporting Methodology

BACKGROUND Adverse event reporting is highly variable and nonstandardized in urologic literature, especially for robot-assisted radical cystectomy (RARC). OBJECTIVE We sought to better characterize complications in patients after RARC using a standardized reporting methodology. DESIGN, SETTING, AND PARTICIPANTS Using a prospectively maintained, single-institution database, we identified 156 consecutive patients who underwent RARC with at least 90 d of follow-up. Complications were analyzed and graded according to the Memorial Sloan-Kettering Cancer Center (MSKCC) system and were defined and stratified by organ system. MEASUREMENTS Logistic regression models were used to define predictors of complications. Cox proportional hazard modeling and Kaplan-Meier survival analyses were used to correlate complications and 90-d mortality. RESULTS AND LIMITATIONS Fifty-two percent (81 of 156) of patients experienced a complication within 90 d of surgery. Sixty-five percent (102 of 156) of patients experienced a postoperative complication at a median follow-up of 9 mo. The highest grade of complication was grade 1 in 30 patients (19%), grade 2 in 34 patients (22%), and grade 3-5 in 38 patients (24%). Twenty-one percent (33 of 156) of patients required hospital readmission. Gastrointestinal, infectious, and genitourinary complications were most common (31%, 25%, and 13%, respectively). The 90-d mortality rate was 5.8%. CONCLUSIONS When reported using strict guidelines, surgical morbidity after RARC is significant, but the majority of complications are low grade. Despite the high prevalence of low-grade complications, the mortality rate was acceptably low. Stringent reporting of complications after RARC is essential for counseling patients, assessing surgical quality, and allowing comparisons with open radical cystectomy and among institutions.

Content validation of a novel robotic surgical simulator.

Study Type – Therapy (case series)
Level of Evidence 4

The First 100 Consecutive, Robot-assisted, Intracorporeal Ileal Conduits: Evolution of Technique and 90-day Outcomes

BACKGROUND Robot-assisted radical cystectomy (RARC) has evolved over the last few years to become an acceptable alternative option to open radical cystectomy. Most series of RARC used an open approach to urinary diversion. Even though robot-assisted intracorporeal urinary diversion (RICUD) is the natural extension of RARC, few centers have reported their experiences with RICUD in general, and in particular, of robot-assisted intracorporeal ileal conduits (RICIC). OBJECTIVE To report our experience with RICIC using the Marionette technique. DESIGN, SETTING, AND PARTICIPANTS The first 100 consecutive patients who underwent RARC and RICIC, and had ≥ 3 mo of postoperative follow-up were included in this study. Patients were divided into four groups of 25 patients each to study the evolution of our surgical technique. INTERVENTION RICIC. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Intraoperative, pathologic, and 90-d postoperative outcomes for the four groups and the overall cohort were compared using the Fisher exact test (categorical variables) and the Kruskal-Wallis test (continuous variables). Continuous variables were reported as median (range) and categorical variables were specified as frequency (percentage). RESULTS AND LIMITATIONS Overall operative and specific diversion times were 352 and 123 min, respectively. Estimated blood loss was 300 ml, lymph node yield was 24, and positive surgical margin rate was 4%. Length of hospital stay increased from 7 d for group 1 to 9 d for group 4. The overall 90-d complication rate was 81%; 19% of complications were high grade. Infections were the most common complications, representing 31% of all complications. There were no statistically significant intergroup differences except in diversion time, intraoperative transfusions, and length of stay. CONCLUSIONS RICIC diversion is safe, feasible, and reproducible. Larger series with longer follow-up are needed to validate the procedure and define its place in the minimally invasive urologic armamentarium. Quality of life studies need to be conducted to compare benefits of intracorporeal urinary diversion.

Is patient outcome compromised during the initial experience with robot-assisted radical cystectomy? Results of 164 consecutive cases.

Study Type – Therapy (case series)

Impact of surgeon and volume on extended lymphadenectomy at the time of robot-assisted radical cystectomy: results from the International Robotic Cystectomy Consortium (IRCC)

Lymph node dissection and its extend during robot‐assisted radical cystectomy varies based on surgeon related factors. This study reports outcomes of robot‐assisted extended lymphadenectomy based on surgeon experience in both academic and private practice settings.

Development and validation of a composite scoring system for robot-assisted surgical trainingdthe Robotic Skills Assessment Score

BACKGROUND A standardized scoring system does not exist in virtual reality-based assessment metrics to describe safe and crucial surgical skills in robot-assisted surgery. This study aims to develop an assessment score along with its construct validation. MATERIALS AND METHODS All subjects performed key tasks on previously validated Fundamental Skills of Robotic Surgery curriculum, which were recorded, and metrics were stored. After an expert consensus for the purpose of content validation (Delphi), critical safety determining procedural steps were identified from the Fundamental Skills of Robotic Surgery curriculum and a hierarchical task decomposition of multiple parameters using a variety of metrics was used to develop Robotic Skills Assessment Score (RSA-Score). Robotic Skills Assessment mainly focuses on safety in operative field, critical error, economy, bimanual dexterity, and time. Following, the RSA-Score was further evaluated for construct validation and feasibility. Spearman correlation tests performed between tasks using the RSA-Scores indicate no cross correlation. Wilcoxon rank sum tests were performed between the two groups. RESULTS The proposed RSA-Score was evaluated on non-robotic surgeons (n = 15) and on expert-robotic surgeons (n = 12). The expert group demonstrated significantly better performance on all four tasks in comparison to the novice group. Validation of the RSA-Score in this study was carried out on the Robotic Surgical Simulator. CONCLUSION The RSA-Score is a valid scoring system that could be incorporated in any virtual reality-based surgical simulator to achieve standardized assessment of fundamental surgical tents during robot-assisted surgery.

Simulation-based robot-assisted surgical training: A health economic evaluation

OBJECTIVE To determine the overall cost effectiveness of surgical skills training on Robotic Surgical Simulator (RoSS). METHODS This study evaluates the cost analysis of utilizing RoSS for robot-assisted surgical training, at Roswell Park Center for Robotic Surgery. Trainees were queried for time spent on the RoSS console over a period of 1 year, starting from June 2010 to June 2011. Time spent was converted to training time consumed on robotic console, resulting in loss of OR time and revenue. The mechanical durability of the RoSS was also determined. RESULTS 105 trainees spent 361 h on the RoSS. This duration converted to 73 robot-assisted radical prostatectomy cases, and 72 animal lab sessions. RoSS prevented a potential loss of

Construct validation of the key components of Fundamental Skills of Robotic Surgery (FSRS) curriculum--a multi-institution prospective study.

600,000, while 72 animal labs would have cost more than