Chad A. LaGrange

Malfunction of the da Vinci Robotic System During Robot-Assisted Laparoscopic Prostatectomy: An International Survey

PURPOSE To determine how urologists manage technical malfunction of the Da Vinci robotic system during robot-assisted radical prostatectomy (RARP). MATERIALS AND METHODS A web-based survey was sent to urologists performing RARP. The survey questions were related to the stage of operation during which robotic malfunction occurred, management of malfunctions, and most common types of robotic malfunction. In addition, data were collected concerning surgical volume and training. RESULTS One hundred (56.8%) of the 176 responding surgeons had experienced an irrecoverable intraoperative malfunction. Eighty respondents experienced mechanical failure before starting RARP, of which 46 (57.5%) rescheduled, 15 (18.8%) performed an open radical approach, 12 (15%) performed standard laparoscopic prostatectomy, and 4 (4.9%) docked another robot. Sixty-three respondents experienced mechanical failure before starting urethrovesical anastomosis, of which 26 (41.2%) converted to an open procedure, 20 (31.7%) converted to standard laparoscopy, 10 (15.8%) finished with one less arm, and 3 (4.7%) aborted the procedure. Thirty-two respondents experienced malfunction before completion of the anastomosis, of which 20 (62.5%) converted to standard laparoscopy, while 12 (37.5%) converted to open surgery. Fellowship trained surgeons were more likely to complete the prostatectomy using standard laparoscopy (P = 0.05). No significant differences existed between surgeons performing a high volume or low volume of prostatectomies in regard to management of malfunctions. CONCLUSION Intraoperative breakdown of the Da Vinci robot is uncommon, but patients should be counseled preoperatively and a plan devised on how breakdown will be managed. Intracorporeal suturing skills allow conversion to a pure laparoscopic approach, if necessary. Consequently, standard laparoscopic suturing skills should remain in the residency curriculum.

Evaluation of Three Laparoscopic Modalities: Robotics versus Three-Dimensional Vision Laparoscopy versus Standard Laparoscopy

PURPOSE Standard laparoscopy has undergone many recent advances with the advent of three-dimensional visual systems and robotic surgical systems. In evaluating the usefulness of these new systems, it is difficult to objectively measure their advantages in the operating room. Therefore, we designed a trial using three different laparoscopic modalities to evaluate the strengths and weaknesses of each modality. MATERIALS AND METHODS Twenty-seven subjects were entered into the study. Three different laparoscopic modalities were tested. These included standard laparoscopy with two-dimensional cameras, the 3Di Endosite visual system, and the daVinci Robotic Surgical System. A standard laparoscopic trainer was utilized and testing consisted of three different tasks: peg transfer, ring manipulation, and cannulation. RESULTS Of the 27 subjects, 16 (60%) reported some degree of laparoscopic experience. The number of pegs transferred with standard laparoscopy and the Endosite 3Di system was significantly greater than with the robot. The number of errors committed during the peg transfer test and the amount of time required was significantly lower with the Endosite 3Di system compared to the robot. Subjects completed the ring manipulation task significantly faster with the robot, but the number of errors committed was no different among the three modalities. Subjects were able to complete the cannulation task with their dominant hand significantly faster with the robot compared to the Endosite 3Di system or standard laparoscopy, and committed fewer errors using the robot compared to standard laparoscopy. CONCLUSIONS This study showed improved performance using three-dimensional optics on some tasks, but not a significant improvement in overall results. Three-dimensional vision does appear beneficial during performance of some complex tasks. The wrist-like action of the robot improved performance on some tasks, while the lack of tactile feedback likely was a source of errors on other tasks.

Human Prostatic Acid Phosphatase: Structure, Function and Regulation

Human prostatic acid phosphatase (PAcP) is a 100 kDa glycoprotein composed of two subunits. Recent advances demonstrate that cellular PAcP (cPAcP) functions as a protein tyrosine phosphatase by dephosphorylating ErbB-2/Neu/HER-2 at the phosphotyrosine residues in prostate cancer (PCa) cells, which results in reduced tumorigenicity. Further, the interaction of cPAcP and ErbB-2 regulates androgen sensitivity of PCa cells. Knockdown of cPAcP expression allows androgen-sensitive PCa cells to develop the castration-resistant phenotype, where cells proliferate under an androgen-reduced condition. Thus, cPAcP has a significant influence on PCa cell growth. Interestingly, promoter analysis suggests that PAcP expression can be regulated by NF-κB, via a novel binding sequence in an androgen-independent manner. Further understanding of PAcP function and regulation of expression will have a significant impact on understanding PCa progression and therapy.

Induction of Progressive Profound Hypocitraturia with Increasing Doses of Topiramate

OBJECTIVES To provide prospective, longitudinal evidence of the effects of topiramate, an antiepileptic medication prescribed for migraine headaches, on stone-risk factors, specifically as pertaining to dosing and rapidity of onset. METHODS Patients scheduled to begin topiramate therapy were recruited to participate in the study. Enrolled subjects collected a pretreatment 24-hour urine specimen with subsequent 24-hour urine specimens collected 5 days after beginning topiramate and after each dose escalation. RESULTS Six subjects enrolled in the study, 4 of whom completed two additional urine collections after initiating topiramate therapy. The pretreatment urine collections of the 4 subjects with additional samples revealed the following mean (range) values: urine volume 1550 (1300 to 1900) mL, pH 6.75 (6 to 7), creatinine 1436.3 (1196 to 1590) mg/day, calcium 305.8 (209 to 423) mg/day, and citrate 606.8 (290 to 860) mg/day. Five days after initiation of topiramate, mean calcium decreased to 211.5 mg/day (31% decrease), and mean citrate decreased to 398 (99 to 804) mg/day, an average decrease of 39.8% (6.5% to 65.9%) per patient. After a dose escalation, calcium increased to 286.8 mg/day, but citrate decreased further to 209 (119 to 353) mg/day, an average decrease of 65.1% (57.9% to 71.7%) per patient from pretreatment levels. CONCLUSIONS Topiramate therapy induces a profound decrease in urinary citrate levels, equivalent to the levels seen in distal renal tubular acidosis. Citrate levels decrease quickly after the start of topiramate therapy and continue to decrease with escalating doses.

Quality and Safety of Minimally Invasive Surgery: Past, Present, and Future

Adverse events because of medical errors are a leading cause of death in the United States (US) exceeding the mortality rates of motor vehicle accidents, breast cancer, and AIDS. Improvements can and should be made to reduce the rates of preventable surgical errors because they account for nearly half of all adverse events within hospitals. Although minimally invasive surgery (MIS) has proven patient benefits such as reduced postoperative pain and hospital stay, its operative environment imposes substantial physical and cognitive strain on the surgeon increasing the risk of error. To mitigate errors and protect patients, a multidisciplinary approach is needed to improve MIS. Clinical human factors, and biomedical engineering principles and methodologies can be used to develop and assess laparoscopic surgery instrumentation, practices, and procedures. First, the foundational understanding and the imperative to transform health care into a high-quality and safe system is discussed. Next, a generalized perspective is presented on the impact of the design and redesign of surgical technologies and processes on human performance. Finally, the future of this field and the research needed to further improve the quality and safety of MIS is discussed.

Ergonomic evaluation of laparoendoscopic single-site surgery ports in a validated laparoscopic training model

Although laparoendoscopic single-site surgery (LESS) is feasible among expert laparoscopic surgeons, it poses many technical challenges not seen in conventional laparoscopy (CL). Recent technological advancements in single-incision instrumentation have created more interest and widespread usage of LESS. However, neither LESS nor its novel instrumentation have been thoroughly studied or evaluated using human factors and ergonomics techniques. Consequently, the aim of this study was to compare the physical performance of LESS to CL using a standardized task. Wrist and elbow angular movements, range of motion and physical discomfort were assessed for 24 novice participants. There were no significant differences for physical comfort/discomfort ratings or elbow and wrist flexion/extension range of motion between CL and LESS. However, wrist radial/ulnar range of motion was significantly greater in LESS compared to CL (p < 0.05). Additionally, wrist radial/ ulnar range of motion was significantly greater using the SILS Port compared to the GelPOINT (p < 0.05). Although further investigation is needed, LESS resulted in greater wrist deviation and range of motion due to the close proximity of the instruments, restrictive nature of the single-port devices, and the need to achieve adequate instrument triangulation and visualization.

Hand-Assisted Laparoscopic Partial Nephrectomy Without Formal Collecting System Closure: Perioperative Outcomes in 104 Consecutive Patients

BACKGROUND AND PURPOSE Laparoscopic partial nephrectomy (LPN) paralleling open techniques, particularly closure of the collecting system, can be technically challenging for the novice laparoscopist. We describe operative results and complications of a single surgeon, retrospectively reviewed series using a simplified method of hand assistance and a fibrin glue patch for hemostasis without formal collecting system closure. PATIENTS AND METHODS We identified 104 consecutive patients between September 2003 and January 2009 who underwent hand-assisted laparoscopic partial nephrectomy (HALPN). Our technique involves routine hilar clamping after isolation of the tumor and mobilization of the kidney. After resection of the mass, a fibrin glue patch is placed within the surgical defect and secured with bolstering sutures. No attempt is made to suture the collecting system, nor are ureteral catheters placed when the collecting system is entered during resection of the tumor. RESULTS Mean tumor size was 2.8 cm (median 2.5 cm, range 0.7-7.0 cm). With hilar clamping, warm ischemia time averaged 24.5 minutes (range 11-39 min). Estimated blood loss averaged 220 mL (range 50-1500 mL), and five (4.8%) patients received transfusions either intraoperatively or postoperatively. Urine leak occurred in 1.9% (n=2) of patients overall and 4.3% (2/47) of patients with documented collecting system entry. Both urine leaks resolved with conservative management only. CONCLUSIONS HALPN without formal collecting system closure is a safe and effective technique with similar urine leak and transfusion rates compared with other series. This technique may allow more urologists to perform minimally invasive partial nephrectomy or to do so with potentially shorter ischemia times.

Patient–Provider Communication About Prostate Cancer Screening and Treatment New Evidence From the Health Information National Trends Survey

The American Urological Association, American Cancer Society, and American College of Physicians recommend that patients and providers make a shared decision with respect to prostate-specific antigen (PSA) testing for prostate cancer (PCa). The goal of this study is to determine the extent of patient–provider communication for PSA testing and treatment of PCa and to examine the patient specific factors associated with this communication. Using recent data from the Health Information National Trends Survey, this study examined the association of patient characteristics with four domains of patient–provider communication regarding PSA test and PCa treatment: (1) expert opinion of PSA test, (2) accuracy of PSA test, (3) side effects of PCa treatment, and (4) treatment need of PCa. The current results suggested low level of communication for PSA testing and treatment of PCa across four domains. Less than 10% of the respondents report having communication about all four domains. Patient characteristics like recent medical check-up, regular healthcare provider, global health status, age group, marital status, race, annual household income, and already having undergone a PSA test are associated with patient–provider communication. There are few discussions about PSA testing and PCa treatment options between healthcare providers and their patients, which limits the shared decision-making process for PCa screening and treatment as recommended by the current best practice guidelines. This study helps identify implications for changes in physician practice to adhere with the PSA screening guidelines.

Ergonomic comparison of laparoscopic hand instruments in a single site surgery simulator with novices

Abstract Background: Single-site surgery improves cosmesis but increases procedural difficulty. Enhanced instruments could improve procedural efficiency leading to better patient outcomes. Material and methods: One pair of non-articulating (straight) and two different pairs of articulating laparoscopic instruments were evaluated using a peg-transfer surgical task simulator by premedical college students. The instruments were comparatively tested using task performance measures, ergonomic measures, and participant questionnaires. Results: The straight instrument produced significantly higher task performance scores and lower task times compared to both articulating instruments (p < 0.05). The straight instrument required less muscle activation and less wrist deviation than the articulating instruments to perform the same task. Participants rated the straight instrument significantly easier to use and less difficult to complete the task than with either articulating instrument (p < 0.05 for both). Conclusions: This exploratory study suggests that novices have difficulty using articulating instruments and perform better using straight laparoscopic instruments when first attempting LESS surgical tasks. Although a study with post-graduate medical trainees is needed to confirm these results, trainees should initially practice LESS with non-articulating instruments to gain proficiency at basic laparoscopic tasks. Additionally, redesigning articulating instruments to specifically address the spatial constraints and learning curve of LESS may also improve trainee performance and instrument usability.

Effect of robotic manipulation on unidirectional barbed suture integrity: evaluation of tensile strength and sliding force.

BACKGROUND AND PURPOSE One of the more challenging portions of robot-assisted radical prostatectomy (RARP) is the urethrovesical anastomosis. Because of this, a unidirectional absorbable barbed suture (V-Loc(™)) has been used to complete the anastomosis with better efficiency and less tension. The effect of robotic needle driver manipulation on barbed suture is unknown. Therefore, the aim of this study is to determine whether robotic manipulation decreases the tensile strength and peak sliding force of V-Loc barbed suture. MATERIALS AND METHODS Fifty-six V-Loc sutures were compared with 56 Maxon sutures. All sutures were 3-0 caliber. Half of the sutures in each group were manipulated with a da Vinci(®) robot large needle driver five times over a 5 cm length of suture. The other half was not manipulated. Breaking force was determined by placing sutures in a Bose ElectroForce load testing device. For sliding force testing, 28 V-Loc sutures were manipulated in the same fashion and compared with 28 nonmanipulated V-Loc sutures. Peak force needed to make the suture slip backward in porcine small intestine was determined to be the sliding force. Scanning electron microscopy of the barbs before and after robotic manipulation was also performed. RESULTS The mean difference in breaking forces for manipulated vs nonmanipulated Maxon sutures was 4.52 N (P=0.004). The mean difference in breaking forces for manipulated vs nonmanipulated V-Loc sutures was 1.30 N (P=0.046). The manipulated V-Loc group demonstrated a lower peak sliding force compared with the nonmanipulated group (0.76 vs 0.88 N, P=0.199). Electron microscopy revealed minor structural damage to the barbs and suture. CONCLUSION Tensile strength and peak sliding force of V-Loc suture is decreased by robotic manipulation. This is likely because of structural damage to the suture and barbs. This structural damage, however, is likely not clinically significant.