M. Shamim Khan

Face, content and construct validity of a virtual reality simulator for robotic surgery (SEP Robot)

INTRODUCTION This study aims to establish face, content and construct validation of the SEP Robot (SimSurgery, Oslo, Norway) in order to determine its value as a training tool. SUBJECTS AND METHODS The tasks used in the validation of this simulator were arrow manipulation and performing a surgeons knot. Thirty participants (18 novices, 12 experts) completed the procedures. RESULTS The simulator was able to differentiate between experts and novices in several respects. The novice group required more time to complete the tasks than the expert group, especially suturing. During the surgeons knot exercise, experts significantly outperformed novices in maximum tightening stretch, instruments dropped, maximum winding stretch and tool collisions in addition to total task time. A trend was found towards the use of less force by the more experienced participants. CONCLUSIONS The SEP robotic simulator has demonstrated face, content and construct validity as a virtual reality simulator for robotic surgery. With steady increase in adoption of robotic surgery world-wide, this simulator may prove to be a valuable adjunct to clinical mentorship.

Ischaemic priapism: A clinical review

OBJECTIVE Ischaemic priapism is a rare condition characterised by little or no cavernosal blood flow, pain and rigidity of the penis. Immediate intervention is required to restore blood flow, prevent necrosis and erectile dysfunction. This review was conducted to determine the best course of treatment and identify areas in current guidelines to which improvements could be made. MATERIAL AND METHODS PubMed, Ovid, MEDLINE (1946-December 2016) and the Cochrane Library were searched as sources for literature. Key studies in each of the areas of management were identified and analysed. RESULTS A total of 45 articles were reviewed. The first step in treatment should be aspiration of corporeal blood. Further studies are needed to make firm recommendations as to whether irrigation should follow, as currently literature is inconclusive. If this fails to cause detumescence, sympathomimetics should be injected. The sympathomimetic of choice is phenylephrine as it is effective, specific and causes minimal cardiovascular side effects. It should be injected at a concentration of 100-500 μg/mL, with 1 mL being injected every 3-5 minutes for up to an hour (maximum 1mg in an hour). Surgical shunting is the next step, except in the cases of delayed priapism (48-72 hours duration) where immediate penile prosthesis insertion may be considered more appropriate. Distal shunts should be performed first, followed by proximal ones to minimise damage leading to erectile dysfunction. There exists little evidence recommending one shunting procedure over another. The final intervention is insertion of a penile prosthesis. Literature suggests that an inflatable prosthesis inserted immediately will yield the greatest patient satisfaction. CONCLUSION A review of the literature has highlighted areas in which further research needs to be done to make conclusive recommendations, including whether irrigation should accompany aspiration and efficacy of shunting procedures. Further studies are required to ensure that patients receive the treatment most likely to cause detumescence and maintain erectile function.

Minimally invasive cystectomy approaches in the treatment of bladder cancer

Bladder cancer is the most frequently occurring tumor of the urinary system, with over 10,000 new diagnoses each year in the UK. Approximately 70% of these are non-muscle-invasive and limited to the mucosa (Ta) or submucosa (T1). These tumors are generally managed with transurethral resection followed by adjuvant intravesical chemo- or immuno-therapy and regular cystoscopic surveillance. The principal end points in the management of these tumors are prevention of recurrence and progression. Muscle-invasive bladder cancer is a life-threatening disease with overall 5-year mortality of 50%. Neoadjuvant chemotherapy, where possible followed by radical surgery, is currently considered the best standard of care. Open radical cystectomy is the gold-standard treatment for muscle-invasive or high-risk non-muscle-invasive (multifocal or recurrence after intravesical therapy) bladder cancer. Historically, this procedure has carried significant morbidity, although mortality of open radical cystectomy has reduced to 1–2% owing to improvements in anesthesia and intensive care facilities. Over the last 15 years, minimally invasive techniques in radical cystectomy have evolved, with the aim of reducing morbidity. In this article, we review the development of laparoscopic radical cystectomy and robot-assisted radical cystectomy, along with current evidence on perioperative morbidity and medium-term oncological outcomes.

ONCOLOGICAL OUTCOMES OF ROBOT-ASSISTED RADICAL CYSTECTOMY

B J U I N T E R N A T I O N A L

Image guided robotic surgery: current evidence for effectiveness in urology.

OBJECTIVES Discussion of the evolution of image guided surgery (IGS) and its fundamental components and current evidence for effectiveness of IGS in clinical urology. METHODS Literature search for image-guided robotic urology. RESULTS Current literature in image-guided robotic urology with its use in robot assisted radical prostatectomy and robot assisted partial nephrectomy are shown. CONCLUSIONS Image guided surgery can be a useful aid to improve visualisation of anatomy and subsurface structures during minimally invasive surgery. Soft-tissue deformation makes it difficult to implement IGS in urology but current studies have shown an attempt to address this issue. The feasibility of IGS requires randomised control trials assessing in particular its accuracy and affect on clinical outcome.

One hand is better than two: conversion from pure laparoscopic to the hand-assisted approach during difficult nephrectomy

INTRODUCTION The incidence of conversion from a laparoscopic to an open approach during nephrectomy is reported at 6-8%. Conversion to an open procedure may be necessary to control haemorrhage or allow progress in dissection but the well established benefits of minimally invasive surgery (MIS) are obviously lost. Hand-assisted laparoscopy (HAL) also offers the benefits to the patient of MIS. We have used HAL to convert from the pure laparoscopic approach during difficult nephrectomies, rather than converting to traditional open surgery. MATERIALS AND METHODS A review of our prospective database was carried out to identify any conversions from the pure laparoscopic approach during nephrectomy or nephroureterectomy for benign or malignant disease. RESULTS A total of 87 laparoscopic nephrectomies (LNs) were identified over a 3-year period. There were five conversions to the HAL approach (5.7%) and no conversions to open surgery. The reason for conversion was failure to progress in all five cases. Operative times averaged 190 minutes with blood loss of 180 ml. Histology revealed xanthogranulomatous pyelonephritis in four cases and renal cell carcinoma in one case. The median postoperative stay was 4 days. CONCLUSIONS Conversion to HAL during LN maintains the benefits of MIS in difficult nephrectomy and should be considered prior to converting to open surgery.

Robotic-Assisted Surgery for Benign Urological Conditions

Robotic technology for use in surgery has advanced considerably in the past 10 years. This has become particularly apparent in urology where robotic-assisted radical prostatectomy using the da Vinci surgical system (Intuitive Surgical, CA) has become very popular. The use of robotic assistance for benign urological procedures is less well documented. This article considers the current robotic technology and reviews the situation with regard to robotic surgery for benign urological conditions.

Nontechnical Skills in Surgery: A Systematic Review of Current Training Modalities

BACKGROUND The complexity of the operating room requires a surgeon to have both technical ability and an array of nontechnical skills. The emphasis on technical skills during surgical training is well established, however it is deficiencies in nontechnical skills that have been identified as the main cause of errors in the operating room. OBJECTIVE This systematic review aims to identify current methods used to teach nontechnical skills and how these methods are assessed to determine their validity, evidence, and role in training. METHODS MEDLINE and Embase databases were searched for English language articles between 2000 and 2017 for nontechnical surgical skills training. Original research articles were included if they described non-technical surgical skills training modalities and their assessment. Results were assessed for the level of evidence and each modality was awarded a level of recommendation, using a modified educational Oxford Centre for Evidence-Based Medicine classification, as adapted by the European Association of Endoscopic Surgery. RESULTS A total of 19 studies were identified pertaining to high fidelity simulation (n = 8), low fidelity simulation (n = 6), didactic teaching (n = 2) and crisis resource management (n = 3). Of the included studies 1 was classified Level 1b, 1 level 2b, 7 level 2b, 2 level 2c, and 8 level 3. CONCLUSION With the importance of nontechnical skills being increasingly recognized, it is essential for surgeons to receive adequate training in nontechnical skills. Therefore the most valuable teaching modalities such as high and low fidelity simulation needs to be implemented into surgical training curricula.

Recurrent Urinary Tract Infections in Adults

Urinary tract infections (UTIs) are an all too frequent clinical problem faced by health care professionals both in the community and in hospital. Whilst most resolve with no residual morbidity, recurrent UTIs can pose a significant management challenge in susceptible patients. This chapter provides a step-by-step guide into investigations of recurrent UTIs and highlights key points in management.