Variability in prostate cancer detection among radiologists and urologists using MRI fusion biopsy.

Objectives: The aim of this study is to evaluate the impact of radiologist and urologist variability on detection of prostate cancer (PCa) and clinically significant prostate cancer (csPCa) with magnetic resonance imaging (MRI)-transrectal ultrasound (TRUS) fusion prostate biopsies. Patients and methods: The Prospective Loyola University MRI (PLUM) Prostate Biopsy Cohort (January 2015 to December 2020) was used to identify men receiving their first MRI and MRI/TRUS fusion biopsy for suspected PCa. Clinical, MRI and biopsy data were stratified by radiologist and urologist to evaluate variation in Prostate Imaging-Reporting and Data System (PI-RADS) grading, lesion number and cancer detection. Multivariable logistic regression (MVR) models and area under the curve (AUC) comparisons assessed the relative impact of individual radiologists and urologists. Results: A total of 865 patients (469 biopsy-naïve) were included across 5 urologists and 10 radiologists. Radiologists varied with grading 15.4% to 44.8% of patients with MRI lesions as PI-RADS 3. PCa detection varied significantly by radiologist, from 34.5% to 66.7% (p = 0.003) for PCa and 17.2% to 50% (p = 0.001) for csPCa. Urologists' PCa diagnosis rates varied between 29.2% and 55.8% (p = 0.013) and between 24.6% and 39.8% (p = 0.36) for csPCa. After adjustment for case-mix on MVR, a fourfold to fivefold difference in PCa detection was observed between the highest-performing and lowest-performing radiologist (OR 0.22, 95%CI 0.10-0.47, p < 0.001). MVR demonstrated improved AUC for any PCa and csPCa detection when controlling for radiologist variation (p = 0.017 and p = 0.038), but controlling for urologist was not significant (p = 0.22 and p = 0.086). Any PCa detection (OR 1.64, 95%CI 1.06-2.55, p = 0.03) and csPCa detection (OR 1.57, 95%CI 1.00-2.48, p = 0.05) improved over time (2018-2020 vs. 2015-2017). Conclusions: Variability among radiologists in PI-RADS grading is a key area for quality improvement significantly impacting the detection of PCa and csPCa. Variability for performance of MRI-TRUS fusion prostate biopsies exists by urologist but with less impact on overall detection of csPCa.

Single port robotic radical prostatectomy versus multi-port robotic radical prostatectomy: A human factor analysis during the initial learning curve.

BACKGROUND: Studies have thus far neglected to evaluate the impact of the da Vinci single port (SP) robotic platform on surgeon experience and operating room efficiency. We sought to assess the effect of the SP platform on surgeon cognitive load measures during robotic assisted laparoscopic prostatectomy (RALP). METHODS: We prospectively compared the first 20 SP-RALPs performed at our institution to 20 multi-port (MP)-RALPs performed by a single experienced robotic surgeon. Three multi-dimensional assessment tools were used to evaluate mental and surgical workload, teamwork and workflow disruptions. RESULTS: No statistically significant differences were found between the MP-RALP and SP-RALP cohorts when evaluated by NASA Task Load Index, Surgery Task Load Index and Observational Teamwork Assessments. CONCLUSIONS: The SP robotic platform did not adversely affect human factor performance of the surgeon during RALP. Multi-institutional validation will be necessary to confirm these initial findings.

Single port robotic radical prostatectomy with the da Vinci SP platform: a step by step approach.

The da Vinci single port (SP) robotic system (Intuitive Surgical, Sunnyvale, CA, USA) is a recently approved robotic platform designed with several modifications to the previously available multi-port robotic systems. This article describes the technique performed utilizing the SP robotic system for radical robotic-assisted laparoscopic prostatectomy (RALP) with or without bilateral pelvic lymph node dissection from a single institution. In this report we describe our step-by-step approach, technical modifications from the multi-port technique and initial results for performing single port robotic-assisted laparoscopic prostatectomy (SP-RALP). We describe our initial experience and technique with the SP robotic system consisting of 23 consecutive patients who underwent SP-RALP between December 2018 and May 2019. The median patient age was 62 years with approximately half of the patients undergoing pelvic lymphadenectomy. The median operative time was 236 minutes, median estimated blood loss was 50 mL and median length of hospital stay was 1 day. No unplanned port placements occurred and no conversions to open surgery occurred. We demonstrate the safety and feasibility of performing a transperitoneal prostatectomy with either a posterior or anterior approach.

Single port robotic radical prostatectomy: a systematic review.

Several studies have assessed the safety and feasibility of single port robot-assisted radical prostatectomy using different and custom built robotic-assisted technology. In part due to the non-standardized nature of these approaches, single site robotic prostatectomy has not been widely adopted. With the recent approval of the da Vinci (Intuitive Surgical, Sunnyvale CA) Single Port (SP) platform, there has been a renewed interest in single site robotic-assisted prostatectomy and several institutions have begun reporting their initial experiences with this technique. In this systematic review, we sought to assess and summarize the literature regarding patient outcomes for single site robotic-assisted prostatectomy and evaluate its role in surgical treatment of prostate cancer. This systematic review was structured using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies describing the use of any robotic platform, including da Vinci Si, Xi or SP platforms for robotic single-port or single site radical prostatectomy between 2000 and July 15, 2019 were eligible for inclusion in this systematic review. Studies were excluded if they included combined cases with other organ resection, represented use in a non-clinical setting (such as a cadaveric model), or described results for a simple prostatectomy technique. Data was extracted by two authors with concerns resolved by consensus. Primary outcomes were mean operative times, estimated blood loss (mL), and hospital length of stay (days). Secondary outcomes included intraoperative conversion to open surgery, and intraoperative and postoperative complications. Variables of interest included sample size (n), mean age (years), mean prostate size (mL), prostate specific antigen (PSA, ng/mL), Gleason score, clinical and pathological TNM staging [American Joint Commission on Cancer (AJCC)], lymph nodes (n) and perioperative complications as available. A total of 217 studies were reviewed by title and abstract, with 28 selected for full-text review; ultimately, 12 studies were included, with available data from 145 patients. Primary outcomes and preoperative characteristics varied greatly amongst patients and across studies. One patient (0.7%) required conversion to a multi-port approach and there were no conversions to an open technique. No intraoperative complications were reported, and no Clavien grade III or greater postoperative complications have been described in the initial 81 radical prostatectomies performed with the SP platform. Single Port techniques appear to represent a safe and feasible approach for performing the minimally invasive radical prostatectomy. The current available literature on the single port radical prostatectomy is weak and consists of single center studies with small sample sizes, short-term follow up and limited functional data. More rigorous multi-center trials with standardized metrics for reporting functional outcomes as well as long-term cancer specific survival are necessary to validate these initial studies.

Single Port and Multiport Approaches for Robotic Vaginoplasty With the Davydov Technique.

OBJECTIVE: To demonstrate the feasibility, surgical technique, and initial outcomes of robotic vaginoplasty with peritoneal flap (Davydov) technique for vaginal reconstruction. METHODS: Following appropriate preoperative patient counseling, 11 consecutive patients underwent robotic vaginoplasty with the da Vinci (Intuitive Surgical, Sunnyvale CA) multiport Xi and single port robotic platforms. Perioperative and postoperative outcomes of interest were retrospectively collected. RESULTS: Between March 2019 and October 2019, a total of 11 patients have undergone robotic vaginoplasty with peritoneal flap technique at our institution-9 using the da Vinci single port platform and 2 using the da Vinci Xi platform. Reasons for vaginoplasty included primary gender-affirming genital reconstruction, vaginal stenosis after gender confirmation surgery, and vaginal hypoplasia secondary to disorders of sexual development. Mean operative time was 267.2 ± 85.9 minutes. Initial postoperative mean vaginal depth was 13.9 ± 0.5 cm. Mean estimated blood loss was 131.8 ± 92.9 mL. Mean length of stay was 5.2 ± 0.6 days and time to return of bowel function was 1.7 ± 0.9 days. Thirty-day readmission rate was 18% (N = 2/11) with 1 patient (9%) requiring surgical revision of the neovagina. CONCLUSION: Robotic-assisted Davydov technique is a potentially applicable, efficacious, and safe method of vaginal reconstruction in cisgender and transgender individuals.

Single-port robotic surgery: the next generation of minimally invasive urology.

INTRODUCTION: The da Vinci Single-Port (SP) platform (Intuitive Surgical Inc, Sunnyvale CA) is a recently approved robotic surgical platform which features several novel modifications from previously available single trocar models including a flexible camera, articulating instruments, and navigator guidance for real-time monitoring of instrument position. We sought to describe our clinical experience with this device as well as to review the current literature related to the use of the SP platform. METHODS: We provide a narrative review of clinical data related to single-port robotic surgery within the field of urology. In addition, we report our initial clinical experience for surgical procedures performed with the SP platform between December 2018 and April 2019 following installation of the system at our institution. RESULTS: Currently, the presently available literature for single-port robotic urological surgery consists of single-center case reports and series. Most major robotic urologic operations appear technically feasible using the da Vinci SP platform; however, additional multi-center studies and randomized trials are needed to determine what role the SP platform will play. CONCLUSIONS: Rather than an iterative step or a niche system, the SP platform provides for a new approach to single-site laparoscopic or robotic techniques and is demonstrated as a feasible approach for several major robotic urological operations. While comparative studies will be required to evaluate perioperative and long-term outcomes between SP and multi-port platforms, further technological advances will continue to push surgeons towards less morbid and more minimally invasive approaches for surgery.

Use of a Novel Articulating Laparoscopic Needle Driver for Partial nephrectomy: An Initial Experience.

OBJECTIVES: To demonstrate the clinical feasibility of an articulated laparoscopic needle driver to assist in the performance of laparoscopic partial nephrectomy (LPN). Previous studies have demonstrated under-utilization of minimally invasive techniques for patients undergoing partial nephrectomy (PN). METHODS: Consecutive patients with renal masses amenable to PN underwent LPN with an articulating laparoscopic needle driver. A consecutive cohort of patients who previously underwent robot assisted laparoscopic PN (RALPN) was selected as a comparison cohort. Preoperative, perioperative, and postoperative variables were retrospectively collected. RESULTS: A total of 20 patients underwent PN with 10 patients assigned to each of the LPN and RALPN cohorts. Median R.E.N.A.L. nephrometry scores assigned to the LPN and RALPN cohorts were 7 and 6 respectively (P= .31). Median warm ischemia time for patients in the LPN and RALPN groups was 25.5 and 18.5 minutes respectively (P= .36). Median estimated blood loss for LPN and RALPN was 200 and 50 mL (P= .03). Median operative time for LPN and RALPN was 203 and 194 minutes respectively (P= .76). Median Length of stay after LPN and RALPN was similar (3.0 vs 2.5 nights, P= .26). Following LPN, 3 patients required blood transfusion as compared to 2 patients in the RALPN cohort (P= .61). CONCLUSION: Our initial results demonstrated the clinical safety and feasibility of a new surgical device for performing LPN. Patients who underwent LPN with a novel articulating needle driver demonstrated equivalent results to RALPN across several key outcomes.

Single-port robot-assisted laparoscopic radical prostatectomy: initial experience and technique with the da Vinci® SP platform.

OBJECTIVES: To assess the safety and feasibility of the da Vinci® SP (Intuitive Surgical, Sunnyvale, CA, USA) robotic platform for a consecutive series of patients who underwent single-port robot-assisted laparoscopic radical prostatectomy (SP-RALP). PATIENTS AND METHODS: In all, 10 consecutive patients with biopsy confirmed prostate cancer underwent SP-RALP at our institution. Pre-, peri-, and postoperative data were prospectively collected for key outcomes including: estimated blood loss (EBL), operative time, postoperative pain requirements, duration of hospital stay, and complications. RESULTS: The patients were aged 52-77 years with a body mass index of 24.4-36.7 kg/m2 . Prostate volumes ranged from 26 to 136 mL, with a mean (sd) PSA (prostate specific antigen) level of 11.0 (10.6) ng/mL. Lymph node dissection was performed in four patients and nerve sparing in five. No intraoperative complications occurred, and no patients required conversion to an open approach. Total EBL was 20-150 mL, with a median (interquartile range [IQR]) console time of 189 (171-207) min and operative time of 234 (216-247) min. No patients were readmitted or required intervention. Urethral catheters were removed at a median (IQR) of 10 (8-11) days after surgery. CONCLUSION: SP-RALP appears to be a safe and feasible approach to performing robotic radical prostatectomy. Long-term follow-up will be necessary to assess initial oncological and functional results.

Optimized Clinical Decision-making: A Configurable Markov Model for Benign Prostatic Hyperplasia Treatment.

OBJECTIVE: To present a configurable mathematical method to optimize long-term clinical decision-making for benign prostatic hyperplasia. METHODS: We designed a Markov chain model to simulate the different health states associated with benign prostatic hyperplasia and the transition between these states based on specific interventions: observation, pharmacotherapy, and 4 types of minimally invasive laser surgery. Transition probabilities, disutility scores, and costs for each health state were derived from the literature, expert opinion, and hospital administration data. Disutility was defined as the complement to one of the utility (1-utility), with utility representing the overall quality of life associated with a particular state. Linear programming was used to compute the Markov decision model. Primary outcomes include cost-effectiveness curves comparing the average treatment cost across permitted disutility levels while considering all modeled interventions. RESULTS: To achieve optimal patient outcomes (low International Prostate Symptoms Score), the model favored surgical interventions and increased costs of treatment. Between different desired disutility values (breakpoints), the model recommends performing 2 recommend treatments in relative proportions to achieve the lowest cost and optimal outcome. The model is limited by its theoretical basis and reliance on literature for transition probabilities and quality of life assessment. CONCLUSION: This model provides a tool for doctors, administrators, and patients to optimize cost-efficacy when considering multiple treatments and different severities of benign prostatic hyperplasia and may be configured to other disease states or clinical practices. Further studies are necessary to validate this model for real-life application.

Incidence of acute mastoiditis in Colorado children in the pneumococcal conjugate vaccine era.

BACKGROUND: Acute otitis media is among the most common reasons young children seek medical care, with Streptococcus pneumoniae the most common pathogen. Despite introduction of heptavalent pneumococcal conjugate vaccine (PCV7) in 2000, recent experience suggests an increase in complications of acute otitis media, particularly acute mastoiditis. METHODS: We performed a retrospective review of acute mastoiditis in children from 1999 to 2008 using inpatient data from the Colorado Hospital Association and the Children's Hospital Colorado. The study included patients with documentation of acute mastoiditis or mastoidectomy and excluded those with chronic mastoiditis, chronic otitis media or cholesteatoma. RESULTS: The annual incidence of acute mastoiditis in children <2 years/100,000 population was 11.0 in 2001 before decreasing to 4.6 in 2002 and 4.5 in 2003. The incidence then increased to 12.0 in 2008 (total N = 242). The proportion of S. pneumoniae isolates nonsusceptible to penicillin increased from 0% (0/16) between 1999 and 2004 to 38% (5/13) between 2005 and 2008 (P = 0.03). CONCLUSIONS: The incidence of acute mastoiditis in Colorado children <2 years of age exhibited a dynamic pattern from 1999 to 2008: a significant decline early after introduction of PCV7 that paralleled initial vaccine uptake, followed by an increase in subsequent years to pre-PCV7 levels. Replacement with non-PCV7 pneumococcal serotypes and increased pneumococcal antibiotic resistance may be responsible for the increase in incidence to pre-PCV7 rates. Surveillance of mastoiditis incidence, pathogen distribution and resistance patterns following introduction of 13-valent PCV is warranted.

Donor complications following laparoscopic compared to hand-assisted living donor nephrectomy: an analysis of the literature.

THERE ARE TWO APPROACHES TO LAPAROSCOPIC DONOR NEPHRECTOMY: standard laparoscopic donor nephrectomy (LDN) and hand-assisted laparoscopic donor nephrectomy (HALDN). In this study we report the operative statistics and donor complications associated with LDN and HALDN from large-center peer-reviewed publications. Methods. We conducted PubMed and Ovid searches to identify LDN and HALDN outcome studies that were published after 2004. Results. There were 37 peer-reviewed studies, each with more than 150 patients. Cumulatively, over 9000 patients were included in this study. LDN donors experienced a higher rate of intraoperative complications than HALDN donors (5.2% versus. 2.0%, P < .001). Investigators did not report a significant difference in the rate of major postoperative complications between the two groups (LDN 0.5% versus HALDN 0.7%, P = .111). However, conversion to open procedures from vascular injury was reported more frequently in LDN procedures (0.8% versus 0.4%, P = .047). Conclusion. At present there is no evidence to support the use of one laparoscopic approach in preference to the other. There are trends in the data suggesting that intraoperative injuries are more common in LDN while minor postoperative complications are more common in HALDN.