Syed Johar Raza

Long-term Oncologic Outcomes Following Robot-assisted Radical Cystectomy: Results from the International Robotic Cystectomy Consortium

BACKGROUND Long-term oncologic data on patients undergoing robot-assisted radical cystectomy (RARC) are limited and based largely on single-institution series. OBJECTIVE Report survival outcomes of patients who underwent RARC ≥5 yr ago. DESIGN, SETTING, AND PARTICIPANTS Retrospective review of the prospectively populated International Robotic Cystectomy Consortium multi-institutional database identified 743 patients with RARC performed ≥5 yr ago. Clinical, pathologic, and survival data at the latest follow-up were collected. Patients with palliative RARC were excluded. Final analysis was performed on 702 patients from 11 institutions in 6 countries. INTERVENTION RARC. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Outcomes of interest, recurrence-free survival (RFS), cancer-specific survival (CSS), and overall survival (OS) were plotted using Kaplan-Meier survival curves. A Cox proportional hazards model was used to identify factors that predicted outcomes. RESULTS AND LIMITATIONS Pathologic organ-confined (OC) disease was found in 62% of patients. Soft tissue surgical margins (SMs) were positive in 8%. Median lymph node (LN) yield was 16, and 21% of patients had positive LNs. Median follow-up was 67 mo (interquartile range: 18-84 mo). Five-year RFS, CSS, and OS were 67%, 75%, and 50%, respectively. Non-OC disease and SMs were associated with poorer RFS, CSS, and OS on multivariable analysis. Age predicted poorer CSS and OS. Adjuvant chemotherapy and positive SMs were predictors of RFS (hazard ratio: 3.20 and 2.16; p<0.001 and p<0.005, respectively). Stratified survival curves demonstrated poorer outcomes for positive SM, LN, and non-OC disease. Retrospective interrogation and lack of contemporaneous comparison groups that underwent open radical cystectomy were major limitations. CONCLUSIONS The largest multi-institutional series to date reported long-term survival outcomes after RARC. PATIENT SUMMARY Patients who underwent robot-assisted radical cystectomy for bladder cancer have acceptable long-term survival.

Cognitive skills assessment during robot-assisted surgery: separating the wheat from the chaff.

To investigate the utility of cognitive assessment during robot‐assisted surgery (RAS) to define skills in terms of cognitive engagement, mental workload, and mental state; while objectively differentiating between novice and expert surgeons.

Augmented-reality-based skills training for robot-assisted urethrovesical anastomosis: a multi-institutional randomised controlled trial.

To validate robot‐assisted surgery skills acquisition using an augmented reality (AR)‐based module for urethrovesical anastomosis (UVA).

Development and validation of a composite scoring system for robot-assisted surgical trainingdthe Robotic Skills Assessment Score

BACKGROUND A standardized scoring system does not exist in virtual reality-based assessment metrics to describe safe and crucial surgical skills in robot-assisted surgery. This study aims to develop an assessment score along with its construct validation. MATERIALS AND METHODS All subjects performed key tasks on previously validated Fundamental Skills of Robotic Surgery curriculum, which were recorded, and metrics were stored. After an expert consensus for the purpose of content validation (Delphi), critical safety determining procedural steps were identified from the Fundamental Skills of Robotic Surgery curriculum and a hierarchical task decomposition of multiple parameters using a variety of metrics was used to develop Robotic Skills Assessment Score (RSA-Score). Robotic Skills Assessment mainly focuses on safety in operative field, critical error, economy, bimanual dexterity, and time. Following, the RSA-Score was further evaluated for construct validation and feasibility. Spearman correlation tests performed between tasks using the RSA-Scores indicate no cross correlation. Wilcoxon rank sum tests were performed between the two groups. RESULTS The proposed RSA-Score was evaluated on non-robotic surgeons (n = 15) and on expert-robotic surgeons (n = 12). The expert group demonstrated significantly better performance on all four tasks in comparison to the novice group. Validation of the RSA-Score in this study was carried out on the Robotic Surgical Simulator. CONCLUSION The RSA-Score is a valid scoring system that could be incorporated in any virtual reality-based surgical simulator to achieve standardized assessment of fundamental surgical tents during robot-assisted surgery.

Oncologic Outcomes Following Robot-assisted Radical Cystectomy with Minimum 5-year Follow-up: The Roswell Park Cancer Institute Experience

BACKGROUND Long-term oncologic outcomes following robot-assisted radical cystectomy (RARC) remain scarce. OBJECTIVE To report long-term oncologic outcomes following RARC at a single institution. DESIGN, SETTINGS, AND PARTICIPANTS Retrospective review of 99 patients who underwent RARC for urothelial carcinoma of bladder between 2005 and 2009. INTERVENTION RARC was performed. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Primary outcomes included recurrence-free survival (RFS), cancer-specific survival (CSS), and overall survival (OS), measured by the Kaplan-Meier method. The association between primary outcomes and perioperative and pathologic factors was assessed using a multivariable Cox proportional hazards model. RESULTS AND LIMITATIONS Fifty-one (52%) patients had stage pT3 or higher disease. Eight (8%) patients had positive margins and 30 (30%) had positive lymph nodes (LNs), with a median of 21 LNs removed. Median follow-up for patients alive was 74 mo. The 5-yr RFS, CSS, and OS rates were 52.5%, 67.8%, and 42.4%, respectively. Tumor stage, LN stage, and margin status were each significantly associated with RFS, CSS, and OS. On multivariable analysis, tumor and LN stage were independent predictors of RFS, CSS, and OS, while positive margin status and Charlson comorbidity index predicted worse OS and CSS. Adjuvant chemotherapy predicted RFS only. Retrospective design and lack of open comparison are main limitations of this study. CONCLUSIONS Long-term oncologic outcomes following RARC demonstrate RFS and CSS estimates similar to those reported in literature for open radical cystectomy. Randomized controlled trials can better define outcomes of any alternative technique. PATIENT SUMMARY Survival data 5 yr after RARC for bladder cancer demonstrate that survival outcomes are dependent on the same oncologic parameters as previously reported for open surgery.

Understanding Avoidance, Refusal, and Abandonment of Chemotherapy Before and After Cystectomy for Bladder Cancer

OBJECTIVE To analyze trends in perioperative chemotherapy and optimize use of neoadjuvant chemotherapy for bladder cancer. METHODS From 2005-2012, 284 consecutive patients underwent robot-assisted radical cystectomy at our facility. Patients with disease ≥ T2 and nodal involvement and positive surgical margins were reviewed and considered candidates for referral to medical oncology for chemotherapy. The study was conducted in two phases: phase 1 included 242 consecutive patients between 2005 and 2011, and phase 2 analyzed the effect of changes in 42 patients during a 1-year period (2011-2012). RESULTS In phase 1, 148 patients (61%) were candidates for neoadjuvant chemotherapy (NAC). Consultation for NAC was sought for 44 patients (29%), and 104 (71%) did not receive consultation. Of the 44 patients, 36% received NAC, 7% refused, 32% were recommended for immediate cystectomy, and 25% did not receive NAC for other reasons. Phase 2 was more stringent, with a multidisciplinary approach. Significant improvement in referral and NAC use was seen. About 78% vs 30% of patients were seen by medical oncology for consideration of NAC before robot-assisted radical cystectomy and 71% vs 36% received NAC compared with phase 1. The NAC utilization rate improved from 10.8% to 55% over 1 year with a diligent multidisciplinary approach. Medical comorbidities were the main reason for patients not receiving adjuvant chemotherapy (AC; 30% and 33%). CONCLUSION A multidisciplinary approach and coordination of services can help optimize the use of neoadjuvant chemotherapy for bladder cancer.

Surgical competency for urethrovesical anastomosis during robot-assisted radical prostatectomy: development and validation of the robotic anastomosis competency evaluation.

OBJECTIVE To develop and validate an assessment tool for the performance of urethrovesical anastomosis (UVA). METHODS A multicenter, prospective, observational study was conducted in 2 phases. Phase 1, development and content validation, used a panel of 5 experienced robotic surgeons to develop a 6-domain scoring system, Robotic Anastomosis Competence Evaluation (RACE), to assess technical skills for performing UVA. Phase 2, construct validation and reliability, used 5 blinded experienced robotic surgeons to rate UVA recordings of expert, advanced beginner, and novice groups. Content validation index was determined to report consensus in phase 1. Phase 2 involved comparison of RACE scores among the 3 groups. Wilcoxon rank-sum tests were used to compare RACE scores. RESULTS Two rounds of Delphi methodology achieved consensus on language and content of RACE. Eight experts, 10 advanced beginners, and 10 novice robotic surgeons participated in the validation study. The overall score for the expert group (27.3) was higher than that of the advanced beginner (19.5; P = .04) and novice groups (13.6; P = .001). The advanced beginner and novice groups differed in overall scores (P = .03). CONCLUSION RACE allows evaluation of surgical competence to perform UVA for robot-assisted radical prostatectomy, when using an inanimate model.

Simulation-based robot-assisted surgical training: A health economic evaluation

OBJECTIVE To determine the overall cost effectiveness of surgical skills training on Robotic Surgical Simulator (RoSS). METHODS This study evaluates the cost analysis of utilizing RoSS for robot-assisted surgical training, at Roswell Park Center for Robotic Surgery. Trainees were queried for time spent on the RoSS console over a period of 1 year, starting from June 2010 to June 2011. Time spent was converted to training time consumed on robotic console, resulting in loss of OR time and revenue. The mechanical durability of the RoSS was also determined. RESULTS 105 trainees spent 361 h on the RoSS. This duration converted to 73 robot-assisted radical prostatectomy cases, and 72 animal lab sessions. RoSS prevented a potential loss of

Construct validation of the key components of Fundamental Skills of Robotic Surgery (FSRS) curriculum--a multi-institution prospective study.

600,000, while 72 animal labs would have cost more than

Simulation-Based Training in Robot-Assisted Surgery: Current Evidence of Value and Potential Trends for the Future

72,000 without including initial robot installation, annual maintenance and personnel expenses. The mechanical durability testing determined breakdown at 180 and 360 h for master control and pinch device, which were repaired under warranty. CONCLUSION RoSS is a cost effective surgical simulator for implementation of a simulation-based robot-assisted surgical training program.