Michael Lin-Brande

Objective assessment of robotic surgical technical skill: A systemic review

Purpose: Robotic surgeries, especially in urology, have grown exponentially during the last decade. Various skills assessment tools have been developed. We reviewed the current status, the current challenges and the future needs of robotic evaluations with a focus on urological applications. Materials and Methods: According to PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analysis) criteria 2 paired investigators screened the PubMed®, Scopus® and Web of Science® databases for all full text, English language articles published between 2006 and 2018 using the query (evaluation OR assessment) AND (robot-assisted surgery OR robotic surgery) AND (surgical performance OR surgical skill) AND training. The research design, validity and reliability of each study were ascertained and analyzed. Results: A total of 259 studies were identified, of which 109 were included in the final analysis. We grouped the studies into 2 categories, including manual and automated assessments. Manual evaluation included global skill, procedure specific and error based assessments. For automated assessment we summarized evaluations derived from robotic instrument kinematic tracking data, systems events and surgical video data, and we explored those associations with various domains by manual evaluation. We further reviewed the current progress in automated surgical segmentation and skill evaluation with machine learning and deep learning. Concerns remain regarding efficient and effective surgeon training and credentialing. Conclusions: No universally accepted robotic skills assessment currently exists. The purpose of assessment (training or credentialing) may dictate whether manual or automated surgeon assessment is more suitable. Moving forward, assessment tools must be objective and efficient to facilitate the training and credentialing of competent surgeons.

Primary Whole-gland Cryoablation for Prostate Cancer: Biochemical Failure and Clinical Recurrence at 5.6 Years of Follow-up

We retrospectively evaluated complications and functional and oncologic outcomes of 94 consecutive men who underwent primary whole-gland cryoablation for localized prostate cancer (PCa) from 2002 to 2012. Kaplan-Meier and multivariable Cox regression analyses were performed using a landmark starting at 6 mo of follow-up. In total, 75% patients had DAmico intermediate- (48%) or high- (27%) risk PCa. Median follow-up was 5.6 yr. Median time to prostate-specific antigen (PSA) nadir was 3.3 mo, and 70 patients reached PSA <0.2ng/ml postcryoablation. The 90-d high-grade (Clavien Grade IIIa) complication rate was 3%, with no rectal fistulas reported. Continence and potency rates were 96% and 11%, respectively. The 5-yr biochemical failure-free survival (PSA nadir+2ng/ml) was 81% overall and 89% for low-, 78% for intermediate-, and 80% for high-risk PCa (p=0.46). The median follow-up was 5.6 and 5.1 yr for patients without biochemical failure and with biochemical failure, respectively. The 5-yr clinical recurrence-free survival was 83% overall and 94% for low-, 84% for intermediate-, and 69% for high-risk PCa (p=0.046). Failure to reach PSA nadir <0.2ng/ml within 6 mo postcryoablation was an independent predictor for biochemical failure (p=0.006) and clinical recurrence (p=0.03). The 5-yr metastases-free survival was 95%. Main limitation is retrospective evaluation. Primary whole-gland cryoablation for PCa provides acceptable medium-term oncologic outcomes and could be an alternative for radiation therapy or radical prostatectomy. PATIENT SUMMARY: Cryoablation is a safe, minimally-invasive procedure that uses cold temperatures delivered via probes through the skin to kill prostate cancer (PCa) cells. Whole-gland cryoablation may offer an alternative treatment option to surgery and radiotherapy. We found that patients had good cancer outcomes 5 yr after whole-gland cryoablation, and those with a prostate-specific antigen value ≥0.2ng/ml within 6 mo after treatment were more likely to have PCa recurrence.