David Eldred-Evans

Using the Mind as a Simulator: A Randomized Controlled Trial of Mental Training

OBJECTIVES Laparoscopic simulators have been introduced as safe and effective methods of developing basic skills. Mental training is a novel training method likened to using the mind as a simulator to mentally rehearse the movements of a task or operation. It is widely used by professional athletes and musicians and has been suggested as a technique that could be used by surgical trainees. The purpose of this study was to assess the use of mental training in developing basic laparoscopic skills in novices. METHODS Sixty-four medical students without laparoscopic experience were randomized into 4 groups. The first 3 groups were trained to cut a circle on a box trainer. Group 1 received no additional training (BT), Group 2 received additional virtual reality training (BT + VRS), and Group 3 received additional mental training (BT + MT). The fourth group was trained on a virtual reality simulator with additional mental training (box-free). The following 4 assessment criterias: time, accuracy, precision and overall performance were measured on both the box-trainer and virtual simulator. RESULTS The mental training group (BT + MT) demonstrated improved laparoscopic skills over both assessments. The improvement in skills in the VRS group (BT + VRS) was limited to VRS assessment and not observed in the box assessment. The fourth group (box-free) had the worst performance on both methods of assessment. CONCLUSION The addition of mental training led to improved laparoscopic skills development. It is a flexible technique and has the potential to challenge VRS as a more cost-effective training method associated with lower capital investment. Given the benefits of mental training with further research, it could be considered for inclusion in training curricula.

Impact of Laparoscopic Lens Contamination in Operating Theaters: A Study on the Frequency and Duration of Lens Contamination and Commonly Utilized Techniques to Maintain Clear Vision.

Introduction: In laparoscopy, contamination of the distal lens is problematic. Not only a cause of frustration, repeatedly cleaning the laparoscope takes up significant time and disrupts the operative flow. Our study aims to explore and describe quantitatively this particular issue within the operating theaters of a major teaching hospital. Materials and Methods: We recorded data assessing the occurrence of impaired vision on the screen display and quantified the occurrence, duration, and modality of cleaning events. Data were recorded on a time-line sheet and collected for basic quantitative analysis as reported below. A brief interview with the surgeons was carried out at the end of each procedure. Results: A total of 64 hours of laparoscopy covering 25 procedures in 4 surgical disciplines were observed. The study found that 56% of the operation was performed with a clear display, while 37% of the time was spent impaired vision. Seven percent of the operation was spent cleaning the distal lens. The interviews recorded a unison sense of frustration and safety concerns regarding lens contamination. Conclusions: Our observational study demonstrates that one third of the duration of a laparoscopic procedure is performed without perfectly clear display. The suboptimal display during an operation is similar to that of driving with a dirty windshield and having to step out of the car to clean it before continuing with the journey. The disruption to operative flow is transcribed as frustration felt by surgeons when display is compromised and having to clean the lens. However, the economical impact of cleaning the lens during the operation remains to be demonstrated.

Use of botulinum toxin for voiding dysfunction

The use of botulinum toxin A (BoNT-A) has expanded across a range of lower urinary tract conditions. This review provides an overview of the current indications for BoNT-A in the lower urinary tract and critically evaluates the published evidence within each area. The classic application of BoNT-A has been in the management of refractory neurogenic detrusor overactivity (NDO) and overactive bladder (OAB). There is a large volume of high-quality evidence, including numerous randomized placebo-controlled trials, which demonstrate the efficacy of BoNT-A over a long follow-up period. The culmination of this robust evidence-base has led to onabotulinumtoxin A (onaBoNT-A) receiving regulatory approval as a second-line treatment for NDO at a dose of 200 U and OAB at dose of 100 U. Other applications for BoNT-A are used on an off-license basis and include interstitial cystitis/bladder pain syndrome (IC/BPS), benign prostatic hyperplasia (BPH), and detrusor sphincter dyssynergia (DSD). These applications are associated with a less mature evidence-base although the literature is rapidly evolving. At present, the results for painful bladder syndrome (PBS) are promising and BoNT-A injections are recommended as a fourth line option in recent international guidelines, although larger randomized study with longer follow-up are required to confirm the initial findings. As a treatment for DSD, BoNT-A injections have shown potential but only in a small number of trials of limited quality. No definite recommendation can be made based on the current evidence. Finally, the results for the treatment of BPH have been variable and recent high quality randomized controlled trials (RCTs) have suggested no benefit over placebo so at present it cannot be recommended for routine clinical practice. Future advances of BoNT-A include liposome encapsulated formulations which are being developed as an alternative to intravesical injections.

Prostate imaging features that indicate benign or malignant pathology on biopsy

Accurate diagnosis of clinically significant prostate cancer is essential in identifying patients who should be offered treatment with curative intent. Modifications to the Gleason grading system in recent years show that accurate grading and reporting at needle biopsy can improve identification of clinically significant prostate cancers. Extracapsular extension of prostate cancer has been demonstrated to be an adverse prognostic factor with greater risk of metastatic spread than organ-confined disease. Tumor volume may be an independent prognostic factor and should be considered in conjunction with other factors. Multi-parametric magnetic resonance imaging (MP-MRI) has become an increasingly important tool in the diagnosis and characterization of prostate cancer. MP-MRI allows T2-weighted (T2W) anatomical imaging to be combined with functional and physiological assessment. Diffusion-weighted imaging (DWI) has shown greater sensitivity, specificity and negative predictive value compared to prostate specific antigen (PSA) testing and T2W imaging alone and has a more positive correlation with Gleason score and tumour volume. Dynamic gadolinium contrast-enhanced (DCE) imaging can exhibit difficulties in distinguishing prostatitis from malignancy in the peripheral zone, and between benign prostatic hyperplasia (BPH) and malignancies in the transition zone (TZ). Computer aided diagnosis utilizes software to aid radiologists in detecting and diagnosing abnormalities from diagnostic imaging. New techniques of quantitative MRI, such as VERDICT MRI use tissue-specific factors to delineate different cellular and microstructural phenotypes, characterizing tissue properties with greater detail. Proton MR spectroscopic imaging (MRSI) is a more technically challenging imaging modality than DCE and DWI MRI. Over the last decade, choline and prostate-specific membrane antigen (PSMA) positron emission tomography (PET) have developed as better tools for staging than conventional imaging. While hyperpolarized MRI shows promise in improving the imaging and differentiation of benign and malignant lesions there is further work required. Accurate reading and interpretation of diagnostic investigations is key to accurate identification of abnormal areas requiring biopsy, sparing those in whom benign or indolent disease can be managed by non-invasive means. Embracing and advancing existing technologies is essential in furthering this process.

PD46-05 A RANDOMISED CONTROLLED TRIAL OF COGNITIVE TRAINING FOR TECHNICAL AND NON-TECHNICAL SKILLS IN ROBOTIC SURGERY

INTRODUCTION AND OBJECTIVES: A surgeon’s technical skill may be a major determinant of patient outcomes. Because robotic surgery can be recorded, computer-vision video analysis of skill and technique (VAST) methods may have advantages for assessment that is objective and scalable. To test the hypothesis that specific features in a video can categorize skill, we studied crowdsourced annotated videos of surgeons performing robotic prostatectomy and applied machine learning to determine skill. METHODS: Videos of the anastomosis from 12 surgeons in the Michigan Urological Surgery Improvement Collaborative underwent blinded review by 25 peer surgeons using the Global Evaluative Assessment of Robotic Skills (GEARS) tool (max score 25). Surgeons were categorized into low and high skill based on 0bimanual dexterity0 and 0efficiency0. Robotic instruments were annotated by crowdworkers via a custom-designed Mechanical Turk platform. Using the videos we trained a linear support vector machine (SVM), sampling consecutive frames to study VAST metrics for instruments including velocity, trajectory, smoothness of movement, and relationship to contralateral instrument. We applied the SVM to learn and classify videos into high/low skill. To evaluate performance we used 11 videos as training, and tested on the remaining 1 video, repeating it 12 times and averaged the accuracy. RESULTS: GEARS scores ranged from 15.75 to 23.11, with 9 and 3 surgeons categorized into high and low skill, respectively. In total, 146,309 video frames were annotated by 925 crowdworkers. Instrument annotation included individual points as well as wristed joint movement (Figure). SVM accuracy in skill categorization using individual points on an instrument was 83.3%. Accuracy improved to 91.7% when we assessed joint movement. When we combined assessment with the contralateral instrument, accuracy was 100% in categorizing binary skill level. Instrument metrics most closely related to skill prediction were relationship between needle driver forceps and joint, acceleration, and velocity. CONCLUSIONS: Computer video analysis can be used to predict skill in practicing robotic surgeons. In the future, methods utilizing deep learning to track instruments and calculate skill, may have significant implications for credentialing and quality improvement. Source of Funding: Blue Cross Blue Shield of Michigan; Intuitive Surgical

MP53-13 FREEDOM FROM ANDROGEN DEPRIVATION AND RADIOTHERAPY THERAPY AFTER UPFRONT MINIMALLY INVASIVE SURGERY FOR HIGH-RISK PROSTATE CANCER

Disease characteristics and the impact of MDT on cancer-specific survival (CSS) was assessed using Cox proportional hazard models. CSS was measured from time of BCR following RPþPORT. A propensity-score matched pair analysis between SOC and MDT patients was performed based on known prognostic factors at initial diagnosis (PSA prior to RP, year of RP, RP Gleason Grade, age, pN-status and pT stage). RESULTS: In total, 384 were matched (187:187) with a median follow-up of 64.2 months. Type of treatment (SOC vs. MDT), age at RP, RP Gleason Grade and margin status were significantly associated with cancer-specific survival in multivariate analysis (all p<0.05). After matched-pair analysis, 10 year CSS was 79.4% (95% CI 66.5-88.2)for SOC and 98.8% (95% CI 91.4-98.8) for MDT(p1⁄4 0.002). CONCLUSIONS: MDT to pelvic nodal recurrences of PCa is associated with improved CSS compared to SOC. These data should be considered hypothesis-generating and inform future randomized trials in this setting.