Timothy Tausch

Content and Construct Validation of a Robotic Surgery Curriculum Using an Electromagnetic Instrument Tracker

PURPOSE Rapid adoption of robot-assisted surgery has outpaced our ability to train novice roboticists. Objective metrics are required to adequately assess robotic surgical skills and yet surrogates for proficiency, such as economy of motion and tool path metrics, are not readily accessible directly from the da Vinci® robot system. The trakSTAR™ Tool Tip Tracker is a widely available, cost-effective electromagnetic position sensing mechanism by which objective proficiency metrics can be quantified. We validated a robotic surgery curriculum using the trakSTAR device to objectively capture robotic task proficiency metrics. MATERIALS AND METHODS Through an institutional review board approved study 10 subjects were recruited from 2 surgical experience groups (novice and experienced). All subjects completed 3 technical skills modules, including block transfer, intracorporeal suturing/knot tying (fundamentals of laparoscopic surgery) and ring tower transfer, using the da Vinci robot with the trakSTAR device affixed to the robotic instruments. Recorded objective metrics included task time and path length, which were used to calculate economy of motion. Student t test statistics were performed using STATA®. RESULTS The novice and experienced groups consisted of 5 subjects each. The experienced group outperformed the novice group in all 3 tasks. Experienced surgeons described the simulator platform as useful for training and agreed with incorporating it into a residency curriculum. CONCLUSIONS Robotic surgery curricula can be validated by an off-the-shelf instrument tracking system. This platform allows surgical educators to objectively assess trainees and may provide credentialing offices with a means of objectively assessing any surgical staff member seeking robotic surgery privileges at an institution.

Early Aggressive Treatment of Lichen Sclerosus May Prevent Disease Progression

PURPOSE When not recognized and treated aggressively, lichen sclerosus may progress and cause debilitating symptoms. It also may result in significant morbidity in patients undergoing treatment for urethral strictures because unrecognized, it may result in rapid and severe recurrence after surgical treatment. We present our experience treating patients with lichen sclerosus in an equal access health care system. MATERIALS AND METHODS We performed an institutional review board approved retrospective review of all adult men with lichen sclerosus treated at our institution during a 10-year period. We analyzed all patients diagnosed with lichen sclerosus, and recorded patient demographics and therapies. We recorded characteristics of the disease process including external and internal manifestations. We also recorded the various treatments, and whether the patients experienced recurrence. RESULTS A total of 43 patients were diagnosed with lichen sclerosus during the review period. Of those patients presenting with more severe (urethral) involvement and undergoing 1 or 2-stage urethroplasties, we noted 7 with recurrence. In the remainder of patients presenting with less severe disease who were treated aggressively with clobetasol and/or minor procedures, no recurrences were noted on followup examination, and all of these patients had documented normal flow patterns on noninvasive urodynamics. CONCLUSIONS Our data suggest that early aggressive topical therapy plus minimally invasive surgical therapy to relieve high pressure voiding may prevent the progression of lichen sclerosus in patients who present with limited disease involving the skin and meatus.

Immediate Insertion of a Semirigid Penile Prosthesis for Refractory Ischemic Priapism

The insertion of a penile prosthesis for reduction of ischemic priapism has previously been described for cases of sickle cell disease, delayed presentation, or failure of previous shunt surgery. We report the first case of immediate insertion of a malleable prosthesis as primary surgical therapy for refractory ischemic priapism in a patient with known preexisting erectile dysfunction. We propose a novel management algorithm incorporating the acute insertion of a penile prosthesis as an effective option in the management of refractory ischemic priapism.

Penile Prosthesis Insertion for Acute Priapism

Shunt surgery is not universally successful toward detumescence, may lead to erectile dysfunction, and can make eventual penile prosthesis insertion difficult. Penile prosthesis insertion during a priapistic episode alleviates ischemic pain, allows the patient to resume sexual function sooner, and prevents corporal scarring and shortening that makes subsequent prosthesis implantation difficult.

Initial validation of the ProMIS surgical simulator as an objective measure of robotic task performance

Virtual reality robotic simulation has gained widespread momentum. In order to determine the value of virtual reality robotic simulation and its objective metrics, a reality-based robotic surgical training platform with similar analytic capabilities must be developed and validated. The ProMIS laparoscopic surgical simulator is a widely available reality-based simulation platform that has been previously validated as an objective measure of laparoscopic task performance. In this study, we evaluated the validity of the ProMIS laparoscopic surgical simulator as an objective measure of robotic task performance. Volunteers were recruited from two experience groups (novice and expert). All subjects completed three tasks (peg transfer, precision cutting, intracorporeal suture/knot) in the ProMIS laparoscopic simulator using the da Vinci robotic surgical system. Motion analysis data was obtained by the ProMIS computerized optical tracking system and objective metrics recorded included time, path length, economy of motion, and observer-recorded penalty scores. The novice group consisted of 10 subjects with no previous robotic surgical experience. The expert group consisted of 10 subjects with robotic experience. The expert group outperformed the novice group in all three tasks. Subjects rated this training platform as easy to use, as an accurate measure of their robotic surgical proficiency, and as relevant to robotic surgery. The experts described the simulator platform as useful for training and agreed with incorporating it into a residency curriculum. This study demonstrates that the ProMIS laparoscopic simulator is a face, content, and construct valid reality-based simulation platform that can be used for objectively measuring robotic task performance.

Mechanism of Action of the Transobturator Sling for Post-Radical Prostatectomy Incontinence: A Multi-institutional Prospective Study Using Dynamic Magnetic Resonance Imaging

OBJECTIVE To compare the length of the membranous (functional) urethra in male patients who underwent the male transobturator sling (TOS) for postradical prostatectomy urinary incontinence (PPI). The TOS is in established use for treatment of PPI; however, the precise mechanism of action is unknown. MATERIALS AND METHODS This is a prospective case-controlled study on men undergoing male TOS surgery from 2008 to 2014. The comparison arm included patients without incontinence after radical prostatectomy. All participants underwent dynamic magnetic resonance imaging (MRI) at baseline and this was repeated after TOS placement for those who underwent the procedure. Three standardized points were measured using MRI and compared in both groups in addition to clinical measures. RESULTS Thirty-nine patients were enrolled and 31 patients completed the protocols. The controls (N = 14) had a longer vesicourethral anastomosis to urethra measured at the penile bulb (functional urethral length) distance compared to the pre-TOS group at rest (1.92 cm controls vs 1.27 cm pre-TOS, P = .0018) and at Valsalva (2.13 cm controls vs 1.72 cm pre-TOS, P = .0371). Placement of the sling (N = 17) increased the functional urethral length distance at rest (1.92 cm control vs 1.53 cm post-TOS, P = .09) and at Valsalva (1.94 cm post-TOS vs 2.13 cm control, P = .61), so that the difference was no longer statistically significant. CONCLUSION We identified that one possible mechanism in improvement in stress urinary incontinence post-TOS placement is the lengthening of the vesicourethral anastomosis to bulbar-urethra distance. This is the first such study utilizing dynamics MRI in post prostatectomy controls, incontinent pre-TOS, and post-TOS to assess and show these findings.

MP88-06 THE MECHANISM OF ACTION OF THE MALE TRANSOBTURATOR SLING IS VIA INCREASED FUNCTIONAL LENGTH OF THE MEMBRANOUS URETHRA: A PROSPECTIVE, CONTROLLED STUDY USING DYNAMIC MRI

INTRODUCTION AND OBJECTIVES: We describe the first retropubic suburethral autologous sling created and placed during robotic radical prostatectomy (RARP). Surgical technique and preliminary data regarding its effectiveness in improving early urinary continence (UC) recovery are presented. METHODS: Between November 2013 and February 2014 a cohort of 60 continents and neurologically healthy patients affected by localized prostate cancer and submitted to RARP at single highvolume center were prospectively randomized into sling and non-sling group. Sling technique was performed in the following steps: 1) at the beginning of right pelvic lymphadenectomy, vas deferens was isolated and removed 2) on scrub nurse table the vas deferens specimen was shaped in a 5-cm section and inserted at the middle of 14cm absorbable double end wire 3) the autologous sling obtained was positioned before the time of bladder-urethral anastomosis, immediately below the plane of the reconstructed recto-uretralis muscle and fixed to the periosteum of the pubic branch bilaterally 4) after completion of the vesico-urethral anastomosis, the sling was anchored definitively pulling further and fixing its wire ends in order to give the wanted urethral support. Early UC recovery was assessed at 5 (catheter removal), 10 and 30 days postoperatively through the record of the daily number of pads used and the collection of International Consultation on Incontinence Questionnaire-Urinary Incontinence-Short Form (ICIQ-UI-SF). Chisquare test and Indipendent Sample T-test were used to investigate UC recovery between the two groups. RESULTS: Complete data collection was available for 60/60 (100%) patients. Mean SD age was 63 9.0 years. Mean SD number of pads daily used in non sling and sling group were at 5 days 1.9 1.2 vs 1.7 1.4 (p1⁄40.5); at 10 days 1.8 1.3 vs 1.3 1.3 (p1⁄40.1) and at 30 days 1.1 1.2 vs 0.4 0.8 (p1⁄40.01) respectively. At 1 month mean SD ICIQ-UI-SF score was 1.8 3.4 vs 4.8 4.6 (p1⁄40.01) in sling and nonsling group; moreover sling patients were found to be associated with a pad-free status ( 2: 4.7; p1⁄40.03). CONCLUSIONS: Our initial experience indicates that new designed suburethral autologous sling is technically feasible and may represent a reliable intraoperative solution in order to improve early UC recovery in patients undergoing RARP. Because the improvement in the percentage of UC recovery at one month post-operatively and the absence of surgical complications this technique has become standard in our department.

PD20-05 COST EFFECTIVENESS OF ACUTE INSERTION OF MALLEABLE PENILE PROSTHESIS FOR REFRACTORY ISCHEMIC PRIAPISM IN PUBLIC HOSPITAL SETTING

METHODS: At eight centers a total of fifteen patients with locally positive, but no systemic signs and symptoms of wound / IPP infection were reviewed. If the patient had systemic / septic symptoms, immediate surgical treatment was performed. Basic patient demographics and post-operative data were acquired. All patients were carefully and frequently followed on one to two oral antibiotics. RESULTS: Fifteen patients were retrospectively reviewed. Demographics reveal age of 47 to 70 (mean 59.4), 7 of 15 (47%) being diabetic, 12 Titans / 1 700 / 1 Genesis / 1 Ambicor [has no infection retardant coating] and 11 (73%) were primary implantation with 3 (20%) being replacements and 1 (6.7%) into previous infected IPP scarred corporal bodies. Time to local wound / IPP infection after implantation was 7 to 40 days (mean 20.4 days), 14 (93 %) had incisional wound drainage with some described as large quality of fluid, 3 (20%) had significant swelling, 1 (6.7%) had device skin fixation and 4 (27%) of the 15 patients had significant increase in IPP pain / tenderness. 9 different bacteria isolates were cultured out of the incisional drainage of 7 patients with 3 Staph Epi, 2 pseudomonas, 1 enterococcus, 2 E. coli, 1 staph aurerus, 1 alpha streptococcus and 1 proteus growths. Time to total resolution of symptoms was 21 to 141 (mean 76.2) days with 13 patients having total resolution of symptoms and two currently under observation. CONCLUSIONS: Observation maybe an option for patients with local signs / symptoms of IPP infection, even with incisional drainage of culture positive bacteria, that traditionally indicated immediate surgical intervention. The authors strongly feel that from a medical legal issue this information is important to get into the literature.

Retrograde renal hilar dissection and segmental arterial clamping: a simple modification to achieve super-selective robotic partial nephrectomy

Super-selective vascular control prior to robotic partial nephrectomy (also known as ‘zero-ischemia’) is a novel surgical technique that promises to reduce warm ischemia time. The technique has been shown to be feasible but adds substantial technical complexity and cost to the procedure. We present a simplified retrograde dissection of the renal hilum to achieve selective vascular control during robotic partial nephrectomy. Consecutive patients with stage 1 solid and complex cystic renal masses underwent robotic partial nephrectomies with selective vascular control using a modification to previously described super-selective robotic partial nephrectomy. In each case, the renal arterial branch supplying the mass and surrounding parenchyma was dissected in a retrograde fashion from the tumor. Intra-renal dissection of the interlobular artery was not performed. Intra-operative immunofluorescence was not utilized as assessment of parenchymal ischemia was documented before partial nephrectomy. Data was prospectively collected in an IRB-approved partial nephrectomy database. Operative variables between patients undergoing super-selective versus standard robotic partial nephrectomy were compared. Super-selective partial nephrectomy with retrograde hilar dissection was successfully completed in five consecutive patients. There were no complications or conversions to traditional partial nephrectomy. All were diagnosed with renal cell carcinoma and surgical margins were all negative. Estimated blood loss, warm ischemia time, operative time and length of stay were all comparable between patients undergoing super-selective and standard robotic partial nephrectomy. Retrograde hilar dissection appears to be a feasible and safe approach to super-selective partial nephrectomy without adding complex renovascular surgical techniques or cost to the procedure.

Spontaneous bilateral renal pelvis thrombus formation presenting as anuric acute renal failure.

A 59-year-old woman was admitted to the internal medicine service after presenting to the emergency department with complaints of abdominal pain and hematuria. Upon further evaluation, the patient was found to be significantly coagulopathic secondary to the intentional ingestion of brodifacoum, the active ingredient in D-Con rat poison, in an attempt to commit suicide. The patient was treated and discharged only to return several days later with new pain and the inability to urinate. She was found to be in acute renal failure and renal ultrasonography revealed bilateral ureteral and renal pelvis thrombus leading to acute obstructive nephropathy. She was taken emergently to the operating room for placement of bilateral ureteral stents which resulted in decompression of her collecting system and resolution of her renal failure.