Catherine Lovegrove

Development of a standardised training curriculum for robotic surgery: a consensus statement from an international multidisciplinary group of experts

To explore the views of experts about the development and validation of a robotic surgery training curriculum, and how this should be implemented.

Structured and Modular Training Pathway for Robot-assisted Radical Prostatectomy (RARP): Validation of the RARP Assessment Score and Learning Curve Assessment

BACKGROUND Use of robot-assisted radical prostatectomy (RARP) for prostate cancer is increasing. Structured surgical training and objective assessment are critical for outcomes. OBJECTIVE To develop and validate a modular training and assessment pathway via Healthcare Failure Mode and Effect Analysis (HFMEA) for trainees undertaking RARP and evaluate learning curves (LCs) for procedural steps. DESIGN, SETTING, AND PARTICIPANTS This multi-institutional (Europe, Australia, and United States) observational prospective study used HFMEA to identify the high-risk steps of RARP. A specialist focus group enabled validation. Fifteen trainees who underwent European Association of Urology robotic surgery curriculum training performed RARP and were assessed by mentors using the tool developed. Results produced LCs for each step. A plateau above score 4 indicated competence. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS We used a modular training and assessment tool (RARP Assessment Score) to evaluate technical skills. LCs were constructed. Multivariable Kruskal-Wallis, Mann-Whitney U, and κ coefficient analyses were used. RESULTS AND LIMITATIONS Five surgeons were observed for 42 console hours to map steps of RARP. HFMEA identified 84 failure modes and 46 potential causes with a hazard score ≥8. Content validation created the RARP Assessment Score: 17 stages and 41 steps. The RARP Assessment Score was acceptable (56.67%), feasible (96.67%), and had educational impact (100%). Fifteen robotic surgery trainees were assessed for 8 mo. In 426 RARP cases (range: 4-79), all procedural steps were attempted by trainees. Trainees were assessed with the RARP Assessment Score by their expert mentors, and LCs for individual steps were plotted. LCs demonstrated plateaus for anterior bladder neck transection (16 cases), posterior bladder neck transection (18 cases), posterior dissection (9 cases), dissection of prostatic pedicle and seminal vesicles (15 cases), and anastomosis (17 cases). Other steps did not plateau during data collection. CONCLUSIONS The RARP Assessment Score based on HFMEA methodology identified critical steps for focused RARP training and assessed surgeons. LCs demonstrate the experience necessary to reach a level of competence in technical skills to protect patients. PATIENT SUMMARY We developed a safety and assessment tool to gauge the technical skills of surgeons performing robot-assisted radical prostatectomy. Improvement was monitored, and measures of progress can be used in future to guide mentors when training surgeons to operate safely.

Systematic review of prostate cancer risk and association with consumption of fish and fish-oils: analysis of 495,321 participants

Fish‐oils have a potential role in inflammation, carcinogenesis inhibition and favourable cancer outcomes. There has been increasing interest in the relationship of diet with cancer incidence and mortality, especially for eicosapantaenoic acid (EPA) and docosahexaenoic acid (DHA). This systematic‐analysis of the literature aims to review evidence for the roles of dietary‐fish and fish‐oil intake in prostate‐cancer (PC) risk, aggressiveness and mortality.

MP51-16 DEVELOPMENT AND CONTENT VALIDATION OF A TRAINING AND ASSESSMENT TOOL FOR RAPN

METHODS: This multi-institutional, prospective, longitudinal study occurred from September 2014-June 2015. Healthcare failure mode and effect analysis (HFMEA) was employed in development. The developed RAPN assessment tool was distributed internationally to 13 experts for content validation. RESULTS: The RAPN training tool contained six phases, 26 processes and 50 sub-processes (Figure 1). RAPN was divided into six phases constituting 28 processes, 64 sub-processes and 84 failure modes. “Preparation of operative field” constituted 9 phases, 15 subprocesses, 17 failure modes. “Exposure of surgical plane” had three processes, six sub-processes, 13 failure modes. “Dissection and control of hilum” included five processes, eight sub-processes, nine related failure modes. “Preparation for hilar clamping and tumour excision” was a five-process stage with seven sub-processes, 10 failure modes. “Hilar clamping, warm ischaemia time and tumour excision” encompassed three processes, 13 subprocesses, 19 failure modes. Lastly, “Finalising and closure” had four processes, 16 subprocesses, 19 failure modes. After excluding detectable failure modes and existing control measures, 45 failure modes had median hazard score 4 and were included in RAPN training tool. Content validation occurred across eight institutions worldwide with 13 expert surgeons and their teams of anaesthetists, nurses and technicians. Additionally, the RAPN training tool was circulated among delegates at the European Association of Urology 2015 Annual Congress. All participants agreed that the RAPN training tool incorporated crucial elements of the operation. CONCLUSIONS: This study used HFMEA to develop and content validate a RAPN training tool. Hazard analysis and content validation developed a 26step checklist. Future research will involve validation and application in clinical practice to evaluate the learning curves of RAPN. Source of Funding: None

PD41-06 ROBOT-ASSISTED TRAINING - EXPERT PERFORMANCE IN FULL IMMERSION SIMULATION, SETTING THE BENCHMARK (CONCURRENT VALIDITY)

INTRODUCTION AND OBJECTIVES: To evaluate surgical trainee performance, technical and non-technical skills can be assessed during full immersion simulation. This study aimed to define the benchmark that novices must attain before achieving competency in urethro-vesical anastomosis (UVA). Benchmark scores are important to reflect when a trainee is safe to perform the task on a real patient by providing an objective assessment of a trainee’s performance. METHODS: 14 expert and intermediate robotic surgeons were assessed for technical and non-technical skills whilst performing UVA in full immersion simulation, with actors playing the roles of scrub nurse and anaesthetist. UVA requires suturing the urethra to the bladder. A series of stressors were applied during the task to enable full assessment of non-technical skills. Data was compared to the performance of 22 medical student novices to establish construct validity. Video footage was assessed by an international expert using GEARS and NOTSS. Mean expert scores were then used to define a competency benchmark. RESULTS: There was a statistically significant difference in technical and non-technical skills between novices, intermediates and experts (p 1⁄4 0.031, p 1⁄4 0.047 respectively). As construct validity was displayed, mean expert scores were used to define a benchmark score of 2.9 for technical skills and 2.8 for non-technical skills. There was no significant difference between laparoscopic and robotic experts, suggesting there may be some transference of skill from previous laparoscopic experience. CONCLUSIONS: Trainees should aim to achieve a mean GEARS score of 2.9 and a mean NOTSS score of 2.8 to achieve competency in performing UVA. Using these benchmark scores will help to deem whether a trainee is competent to perform an unassisted UVA on a patient and can be incorporated into robot-assisted surgery training programmes to monitor progression. Future work must be carried out to further evaluate whether there is a role for transference of skills from laparoscopic experience to robot-assisted surgery.

Robotic Training and Validation

Surgical training is undergoing sweeping changes. Having long followed the Halstedian master-apprentice model, new pressures and challenges are transforming the way in which surgeons are taught. Increasing training demands on ever more limited healthcare budgets are driving the need for efficiency. Additionally expectations for zero-complication surgery have led to the expansion of safeguards, and the standardisation of practices. As a result, the traditional model of “learning by doing” dependent on case volume is no longer feasible. Dedicated simulation-based training curricula are required to enable training in the necessary technical and on technical skills.

Role of the Surgeon

In recent years, the role of the surgeon has come under much scrutiny as a consequence of investigations into professional practice. A positive working environment has been shown to promote workers’ motivation and happiness, increasing productivity and reporting of problems as a knock-on effect. This is affected by a wide range of factors, ranging from individual actions to group-work and institutional regulation on a larger scale. This chapter will examine the role of the surgeon in different settings, considering interactions with the workforce and subsequent effects on patient care.

Comparing the diagnostic accuracy of ultrasound in the community and in the hospital setting for urinary calculi: A retrospective cohort study:

Objective: The objective of this article is to test whether there is a significant difference in diagnostic accuracy between hospital and community-based ultrasound (US) for the detection of urinary calculi in the United Kingdom (UK). Materials and methods: A 30-month, single-blind, retrospective cohort study of all patients referred to Kent and Canterbury Hospital urology multidisciplinary meeting for suspected urinary calculi was conducted. Only those investigated with US and non-contrast computed tomography (NCCT, the gold standard) for their calculi were included. Concordance of US and NCCT was stratified by US location: i.e. either the hospital or community setting (e.g. the latter via general practitioners (GPs) or independent radiographers). Fisher’s exact test was subsequently utilised to test for any significant difference between these two patient groups. Results: Of 2464 patients referred, 257 had both ultrasound and NCCT in their diagnostic workup. Of these, 150 and 107 patients had their US performed in hospital and community settings, respectively. No significant difference in the accuracy of US was detected between the two groups for the detection of urinary calculi when compared with NCCT. Conclusion: US carried out by independent radiographers and GPs in the community is just as accurate as US carried out by hospital sonographers for the detection of urinary calculi in the UK. Greater use of community US for the diagnosis of urinary calculi may promote greater patient/GP satisfaction and reduce hospital attendance without loss of diagnostic accuracy.

Safety Checklist for Training and Assessment in Robot-Assisted Prostate Surgery

Use of robot-assisted radical prostatectomy to treat prostate cancer is increasing. Surgical training and assessment must deliver skills required by surgeons for robotic techniques. At present, there is a lack of specific measures, placing patients at risk of harm from unidentified error and inadvertent adverse events in specific, risky procedures. This chapter aims to explore various safety measures that have been developed for training and assessment in robot-assisted surgery.