John S. McGrath

Anesthesia for Major Urologic Surgery

This article details the anesthetic management of robot-assisted and laparoscopic urologic surgery. It includes the key concerns for anesthetists and a guide template for those learning this specialist area. The emphasis is on the principles of enhanced recovery, the preoperative and risk assessments, as well as the specific management plans to reduce the incidence of complications arising as a result of the prolonged pneumoperitoneum and steep head-down positions necessary for most of these procedures.

A prospective analysis of the diagnostic yield resulting from the attendance of 4020 patients at a protocol‐driven haematuria clinic

To clarify the prevalence of disease as determined by age, sex and the degree of haematuria at presentation, and to ascertain the merits of using ultrasonography (US), i.v. urography (IVU) or both when imaging the upper urinary tract, in a prospective cohort of patients attending a protocol‐based haematuria clinic.

Psychomotor control in a virtual laparoscopic surgery training environment: gaze control parameters differentiate novices from experts

BackgroundSurgical simulation is increasingly used to facilitate the adoption of technical skills during surgical training. This study sought to determine if gaze control parameters could differentiate between the visual control of experienced and novice operators performing an eye-hand coordination task on a virtual reality laparoscopic surgical simulator (LAP Mentor™). Typically adopted hand movement metrics reflect only one half of the eye-hand coordination relationship; therefore, little is known about how hand movements are guided and controlled by vision.MethodsA total of 14 right-handed surgeons were categorised as being either experienced (having led more than 70 laparoscopic procedures) or novice (having performed fewer than 10 procedures) operators. The eight experienced and six novice surgeons completed the eye-hand coordination task from the LAP Mentor basic skills package while wearing a gaze registration system. A variety of performance, movement, and gaze parameters were recorded and compared between groups.ResultsThe experienced surgeons completed the task significantly more quickly than the novices, but only the economy of movement of the left tool differentiated skill level from the LAP Mentor parameters. Gaze analyses revealed that experienced surgeons spent significantly more time fixating the target locations than novices, who split their time between focusing on the targets and tracking the tools.ConclusionThe findings of the study provide support for the utility of assessing strategic gaze behaviour to better understand the way in which surgeons utilise visual information to plan and control tool movements in a virtual reality laparoscopic environment. It is hoped that by better understanding the limitations of the psychomotor system, effective gaze training programs may be developed.

Multicenter Assessment of Neoadjuvant Chemotherapy for Muscle-invasive Bladder Cancer

BACKGROUND The efficacy of neoadjuvant chemotherapy (NAC) for muscle-invasive bladder cancer (BCa) was established primarily with methotrexate, vinblastine, doxorubicin, and cisplatin (MVAC), with complete response rates (pT0) as high as 38%. However, because of the comparable efficacy with better tolerability of gemcitabine and cisplatin (GC) in patients with metastatic disease, GC has become the most commonly used regimen in the neoadjuvant setting. OBJECTIVE We aimed to assess real-world pathologic response rates to NAC with different regimens in a large, multicenter cohort. DESIGN, SETTING, AND PARTICIPANTS Data were collected retrospectively at 19 centers on patients with clinical cT2-4aN0M0 urothelial carcinoma of the bladder who received at least three cycles of NAC, followed by radical cystectomy (RC), between 2000 and 2013. INTERVENTION NAC and RC. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS The primary outcome was pathologic stage at cystectomy. Univariable and multivariable analyses were used to determine factors predictive of pT0N0 and ≤pT1N0 stages. RESULTS AND LIMITATIONS Data were collected on 935 patients who met inclusion criteria. GC was used in the majority of the patients (n=602; 64.4%), followed by MVAC (n=183; 19.6%) and other regimens (n=144; 15.4%). The rates of pT0N0 and ≤pT1N0 pathologic response were 22.7% and 40.8%, respectively. The rate of pT0N0 disease for patients receiving GC was 23.9%, compared with 24.5% for MVAC (p=0.2). There was no difference between MVAC and GC in pT0N0 on multivariable analysis (odds ratio: 0.89 [95% confidence interval, 0.61-1.34]; p=0.6). CONCLUSIONS Response rates to NAC were lower than those reported in prospective randomized trials, and we did not discern a difference between MVAC and GC. Without any evidence from randomized prospective trials, the best NAC regimen for invasive BCa remains to be determined. PATIENT SUMMARY There was no apparent difference in the response rates to the two most common presurgical chemotherapy regimens for patients with bladder cancer.

Cheating experience: Guiding novices to adopt the gaze strategies of experts expedites the learning of technical laparoscopic skills

BACKGROUND Previous research has demonstrated that trainees can be taught (via explicit verbal instruction) to adopt the gaze strategies of expert laparoscopic surgeons. The current study examined a software template designed to guide trainees to adopt expert gaze control strategies passively, without being provided with explicit instructions. METHODS We examined 27 novices (who had no laparoscopic training) performing 50 learning trials of a laparoscopic training task in either a discovery-learning (DL) group or a gaze-training (GT) group while wearing an eye tracker to assess gaze control. The GT group performed trials using a surgery-training template (STT); software that is designed to guide expert-like gaze strategies by highlighting the key locations on the monitor screen. The DL group had a normal, unrestricted view of the scene on the monitor screen. Both groups then took part in a nondelayed retention test (to assess learning) and a stress test (under social evaluative threat) with a normal view of the scene. RESULTS The STT was successful in guiding the GT group to adopt an expert-like gaze strategy (displaying more target-locking fixations). Adopting expert gaze strategies led to an improvement in performance for the GT group, which outperformed the DL group in both retention and stress tests (faster completion time and fewer errors). CONCLUSION The STT is a practical and cost-effective training interface that automatically promotes an optimal gaze strategy. Trainees who are trained to adopt the efficient target-locking gaze strategy of experts gain a performance advantage over trainees left to discover their own strategies for task completion.

Perioperative fluid management: Consensus statement from the enhanced recovery partnership

Enhanced Recovery (ER) after Surgery (or Fast Track) is a bundle of ‘best evidence based practices’ delivered by a multi-professional health care team, with the intention of helping patients recover faster after surgery [1]. Professor Henrik Kehlet, a surgeon from Denmark, pioneered the concept more than a decade ago but practitioners in the UK remained sceptical of his amazing results and adoption in the National Health Service (NHS) had been slow [1,2]. The Enhanced Recovery Partnership Programme (ERPP) was set up by the Department of Health in England in May 2009, to encourage the widespread adoption of ER with the aim of improving recovery from major surgery [1,3]. The Programme initially concentrated on elective major surgery in four specialities (Colorectal, Musculoskeletal, Gynaecology and Urology). Audit of ER practice by the early adopters demonstrated greater than 80% compliance with the majority of elements recommended by the ERPP. However, perioperative fluid management including the administration of pre-operative carbohydrate drinks and individualised goal directed fluid management guided by advanced haemodynamic monitoring (e.g. Oesophageal Doppler) had lower levels of compliance [3]. A pilot study using Commissioning for Quality and Innovation (CQUIN) to encourage practice change showed a dramatic improvement in outcomes in North Central London with very high levels of compliance with the ERPP recommended principles of perioperative fluid management, in particular goal directed fluid management [4]. The National Programme has evolved into the Enhanced Recovery Partnership (ERP), and the most recent guide published by the ERP includes evidence of widespread adoption of ER in the NHS in England and achievement of stated goals i.e. reduced length of hospital stay after surgery resulting in more operations being performed despite fewer bed days, no increase in readmissions and high levels of patient satisfaction [5]. Perioperative fluid management is at the heart of Enhanced Recovery and the use of intra-operative fluid management technology, such as Oesophageal Doppler, is supported by the ERP in line with the National Institute of Clinical Excellence (NICE) Guidance (MTG3), the NHS Operating Framework 2012–13 and the Department of Health Innovation Health and Wealth Review 2011 [5-7]. Despite concordance in the guidelines, the veracity of the evidence has been challenged [8,9]. The ERP thought it was timely to produce a consensus statement from the National Clinical Leads and Specialist Advisors within the specific context of Enhanced Recovery and, for the purpose of widespread dissemination, the general principles and key recommendations outlined in the latest guide are reiterated in this article [5]. Of note, no particular evidence based methodology was used aside from seeking unanimous agreement from the authors. A practical and pragmatic set of guidelines and recommendations was the aim. The conclusions do align with the GIFTASUP guidelines and NICE guidance where established EBM methodologies were utilised [6,8,10]. In making this consensus statement we agree that larger, more definitive studies of perioperative fluid management and, in particular, the relative contribution of haemodynamic monitoring compared with fluid restriction would be welcomed [11,12]. However, to be useful, such studies must be conducted in the context of a fully implemented Enhanced Recovery Program.

Consensus views on implementation and measurement of enhanced recovery after surgery in England: Delphi study.

Objective The Department of Healths Enhanced Recovery Partnership Programme (ERPP) started a spread and adoption scheme of Enhanced Recovery After Surgery (ERAS) throughout England. In preparation for widespread adoption the ERPP wished to obtain expert consensus on appropriate outcome measures for ERAS, emerging techniques being widely adopted and proposed methods for the continued development and sustainability of ERAS in the National Health Service. The aim of this study was to interrogate expert opinion and define areas of consensus on these issues. Design A Delphi technique using three rounds of reiterative questionnaires was used to obtain consensus. Participants Experts were chosen from teams with experience of delivering a successful ERAS programme across different surgical specialties and across various disciplines. Setting The first two rounds of the questionnaire were completed online and a final, third round was undertaken in a meeting using interactive voting. Results 86 experts took part in this study. Consensus statements agreed that patient experience data should be recorded, analysed and reviewed at regular ERAS meetings. Recent developments in regional analgesia, the increased use of intraoperative monitoring for fluid management and cardio-pulmonary exercise testing were the main emerging techniques identified. National standards for those outcome measures would be welcomed. To sustain success in ERAS, the experts highlighted clinical champions and the presence of a dedicated ERAS facilitator as essential elements. For future networking, a unanimous agreement was achieved on the formation a national network to facilitate spread and adoption of ERAS and to promote research and education across surgery. Conclusions Consensus was achieved on regular measurement and review of patient experience in ERAS. Agreement was reached on the role of regional analgesia and the use of oesophageal Doppler for intraoperative goal-directed fluid therapy. In order to facilitate the further spread and adoption of best practices and to promote research and education, an ERAS-UK network was recommended.

Perceptual impairment and psychomotor control in virtual laparoscopic surgery

BackgroundIt is recognised that one of the major difficulties in performing laparoscopic surgery is the translation of two-dimensional video image information to a three-dimensional working area. However, research has tended to ignore the gaze and eye-hand coordination strategies employed by laparoscopic surgeons as they attempt to overcome these perceptual constraints. This study sought to examine if measures related to tool movements, gaze strategy, and eye-hand coordination (the quiet eye) differentiate between experienced and novice operators performing a two-handed manoeuvres task on a virtual reality laparoscopic surgical simulator (LAP Mentor™).MethodsTwenty-five right-handed surgeons were categorised as being either experienced (having led more than 60 laparoscopic procedures) or novice (having performed fewer than 10 procedures) operators. The 10 experienced and 15 novice surgeons completed the “two-hand manoeuvres” task from the LAP Mentor basic skills learning environment while wearing a gaze registration system. Performance, movement, gaze, and eye-hand coordination parameters were recorded and compared between groups.ResultsThe experienced surgeons completed the task significantly more quickly than the novices, used significantly fewer movements, and displayed shorter tool paths. Gaze analyses revealed that experienced surgeons spent significantly more time fixating the target locations than novices, who split their time between focusing on the targets and tracking the tools. A more detailed analysis of a difficult subcomponent of the task revealed that experienced operators used a significantly longer aiming fixation (the quiet eye period) to guide precision grasping movements and hence needed fewer grasp attempts.ConclusionThe findings of the study provide further support for the utility of examining strategic gaze behaviour and eye-hand coordination measures to help further our understanding of how experienced surgeons attempt to overcome the perceptual difficulties inherent in the laparoscopic environment.

Patient‐specific risk of undetected malignant disease after investigation for haematuria, based on a 4‐year follow‐up

Study Type – Diagnostic (exploratory cohort)
Level of Evidence 2b

Implementation of the Exeter enhanced recovery programme for patients undergoing radical cystectomy.

To describe our experience with the implementation and refinement of an enhanced recovery programme (ERP) for radical cystectomy (RC) and urinary diversion. To assess the impact on length of stay (LOS), complication and readmission rates.