Surgical innovation revisited: A historical narrative of the minimally invasive "Agarwal sliding-clip renorrhaphy" technique for partial nephrectomy and its application to an Australian cohort.

Objective: To evaluate local clinical outcomes of sliding clip renorrhaphy, from inception to current utilization for open, laparoscopic, and robotically assisted partial nephrectomy. Methods: We reviewed prospectively maintained databases of three surgeons performing partial nephrectomies with the sliding-clip technique at teaching hospitals between 2005 and 2019. Baseline characteristics, operative parameters, including surgical approach, RENAL Nephrometry Score, and post-operative outcomes, including Clavien-Dindo classification of complications, were recorded for 76 consecutive cases. We compared perioperative and 90-day events with patient and tumor characteristics, stratified by operative approach and case complexity, using Wilcoxon rank-sum test for continuous variables and the Chi-squared or Fisher's exact test, for binary and categorical variables, respectively. Results: Open surgery (n = 15) reduced ischemia time and operative time, but increased hospital admission time. Pre- and post-operative estimated glomerular filtration rates did not change significantly by operative approach. Older patients (P = .007) and open surgery (P = .003) were associated with a higher rate of complications (any-grade). Six grade ≥3 complications occurred: these were associated with higher RENAL Nephrometry Score (P = .016) and higher pathological tumor stage (P = .045). Limits include smaller case volumes which incorporate the learning curve cases; therefore, these data are most applicable to lower volume teaching hospitals. Conclusion: The sliding-clip technique for partial nephrectomy was first described by Agarwal et al and has low complication rates, acceptable operative time, and preserves renal function across open and minimally invasive surgeries. This series encompasses the initial learning curve with developing the technique through to present-day emergence as a routine standard of practice.

King's Health Partners' Prostate Cancer Biobank (KHP PCaBB).

The KHP PCaBB was established in 2013 and recruits donors from the Urology or Oncology Departments at Guy's Hospital in London (UK). Prostate cancer patients may be approached to give their consent for biobanking at any point in their treatment pathway, which allows residual material from their earlier diagnosis to be transferred and used by the Biobank. Currently, patients are specifically asked to donate samples of blood and surplus prostate tissue as well as permitting access to their clinical and pathological data that continues to be added throughout the course of their disease. Between 2013 and 2015, 549 prostate cancer patients gave their consent to the biobank and, the tissue repository collected 489 blood samples, 120 frozen prostate tissue samples and 1064 formalin fixed paraffin embedded diagnostic blocks.Prostate cancer has become a chronic disease in a large proportion of men, with many men receiving multiple subsequent treatments, and their treatment trajectory often spanning over decades. Therefore, this resource aims to provide an ideal research platform to explore potential variations in treatment response as well as disease markers in the different risk categories for prostate cancer.A recent audit of the KHP PCaBB revealed that between 2013 and 2015, 1796 patients were diagnosed with prostate cancer at King's Health Partners (KHP), out of which 549 (30.6%) gave their consent to KHP PCaBB. Comparisons between demographic and clinical characteristics of patients who had consented compared to the total patient population revealed that the KHP PCaBB is demographically representative of the total prostate cancer patient population seen in Guy's and St Thomas' NHS Foundation Trust (GSTT). We observed no differences in distribution of ethnicity (p = 0.507) and socioeconomic status (p = 0.097). Some differences were observed in clinical characteristics, specifically with treatment type - which differed significantly between the patients who had given consent and total patient population.The KHP PCaBB has thereby amassed a rich data and tissue repository that is largely reflective of both the demographic and clinical diversity within the total prostate cancer patient population seen at KHP, making it an ideal platform for prostate cancer research.

Robotic surgery with the Da Vinci Xi: simultaneous upper and lower tract surgery.

The evolution of robotic platforms has continued to advance the field and improve outcomes. We review the literature regarding the use of the Da Vinci Xi for simultaneous upper and lower tract surgery, examining outcomes. In colusion, the Xi has allowed evolution of technique and surgical outcomes.

Robotic partial nephrectomy - Evaluation of the impact of case mix on the procedural learning curve.

INTRODUCTION: Although Robotic partial nephrectomy (RPN) is an emerging technique for the management of small renal masses, this approach is technically demanding. To date, there is limited data on the nature and progression of the learning curve in RPN. AIMS: To analyse the impact of case mix on the RPN LC and to model the learning curve. METHODS: The records of the first 100 RPN performed, were analysed at our institution that were carried out by a single surgeon (B.C) (June 2010-December 2013). Cases were split based on their Preoperative Aspects and Dimensions Used for an Anatomical (PADUA) score into the following groups: 6-7, 8-9 and >10. Using a split group (20 patients in each group) and incremental analysis, the mean, the curve of best fit and R(2) values were calculated for each group. RESULTS: Of 100 patients (F:28, M:72), the mean age was 56.4 ± 11.9 years. The number of patients in each PADUA score groups: 6-7, 8-9 and >10 were 61, 32 and 7 respectively. An increase in incidence of more complex cases throughout the cohort was evident within the 8-9 group (2010: 1 case, 2013: 16 cases). The learning process did not significantly affect the proxies used to assess surgical proficiency in this study (operative time and warm ischaemia time). CONCLUSIONS: Case difficulty is an important parameter that should be considered when evaluating procedural learning curves. There is not one well fitting model that can be used to model the learning curve. With increasing experience, clinicians tend to operate on more difficult cases.

Do surgical trainees believe they are adequately trained to manage the ageing population? A UK survey of knowledge and beliefs in surgical trainees.

OBJECTIVE: Increasing numbers of older patients are undergoing surgery. Older surgical patients are at a higher risk of perioperative complications and mortality. Multimorbidity, frailty, and physiological changes of ageing contribute to adverse outcomes. These complications are predominantly medical, rather than directly surgical. Guidelines recommend preoperative assessment of comorbidity, disability, and frailty in older patients undergoing surgery and closer perioperative collaboration between surgeons and geriatricians. We conducted a survey to assess knowledge and beliefs of surgical trainees toward common perioperative problems encountered in older surgical patients. DESIGN: Paper-based survey. SETTING: Unselected UK surgical training-grade physicians (CT1-ST8) attending the 2013 Congress of The Association of Surgeons of Great Britain and Ireland, Glasgow, UK, May 1-3, 2013. PARTICIPANTS: A total of 160 eligible UK surgical trainees attending the conference were invited to participate in the survey. Of them, 157 participated. RESULTS: Of the trainees, 68% (n = 107) reported inadequate training and 89.2% (n = 140) supported the inclusion of geriatric medicine issues in surgical curricula. Of the respondents, 77.2% (n = 122) were unable to correctly identify the key features required to demonstrate mental capacity, and only 3 of 157 respondents were familiar with the diagnostic criteria for delirium. Support from geriatric medicine was deemed necessary (84.7%, n = 133) but often inadequate (68.2%, n = 107). Surgical trainees support closer collaboration with geriatric medicine and shared care of complex, older patients (93.6%, n = 147). CONCLUSIONS: UK surgical trainees believe that they receive inadequate training in the perioperative management of complex, older surgical patients and are inadequately supported by geriatric medicine physicians. In this survey sample, trainee knowledge of geriatric issues such as delirium and mental capacity was poor. Surgical trainees support the concept of closer liaison and shared care of complex, older patients with geriatric medicine physicians. Changes to surgical training and service development are needed.

Systematic review of prostate cancer risk and association with consumption of fish and fish-oils: analysis of 495,321 participants.

INTRODUCTION: Fish-oils have a potential role in inflammation, carcinogenesis inhibition and favourable cancer outcomes. There has been increasing interest in the relationship of diet with cancer incidence and mortality, especially for eicosapantaenoic acid (EPA) and docosahexaenoic acid (DHA). This systematic-analysis of the literature aims to review evidence for the roles of dietary-fish and fish-oil intake in prostate-cancer (PC) risk, aggressiveness and mortality. METHODS: A systematic-review, following PRISMA guidelines was conducted. PubMed, MEDLINE and Embase were searched to explore PC-risk, aggressiveness and mortality associated with dietary-fish and fish-oil intake. 37 studies were selected. RESULTS: A total of 495,321 (37-studies) participants were investigated. These revealed various relationships regarding PC-risk (n = 31), aggressiveness (n = 8) and mortality (n = 3). Overall, 10 studies considering PC-risk found significant inverse trends with fish and fish-oil intake. One found a dose-response relationship whereas greater intake of long-chain-polyunsaturated fatty acids increased risk of PC when considering crude odds-ratios [OR: 1.36 (95% CI: 0.99-1.86); p = 0.014]. Three studies addressing aggressiveness identified significant positive relationships with reduced risk of aggressive cancer when considering the greatest intake of total fish [OR 0.56 (95% CI 0.37-0.86)], dark fish and shellfish-meat (p < 0.0001), EPA (p = 0.03) and DHA (p = 0.04). Three studies investigating fish consumption and PC-mortality identified a significantly reduced risk. Multivariate-OR (95% CI) were 0.9 (0.6-1.7), 0.12 (0.05-0.32) and 0.52 (0.30-0.91) at highest fish intakes. CONCLUSIONS: Fish and fish-oil do not show consistent roles in reducing PC incidence, aggressiveness and mortality. Results suggest that the specific fish type and the fish-oil ratio must be considered. Findings suggest the need for large intervention randomised placebo-controlled trials.

Development of UK guidance on the management of erectile dysfunction resulting from radical radiotherapy and androgen deprivation therapy for prostate cancer.

AIM: To develop a management strategy (rehabilitation programme) for erectile dysfunction (ED) after radiotherapy (RT) or androgen deprivation therapy (ADT) for prostate cancer that is suitable for use in a UK NHS healthcare context. METHODS: PubMed literature searches of ED management in this patient group together with a survey of 28 experts in the management of treatment-induced ED from across the UK were conducted. RESULTS: Data from 19 articles and completed questionnaires were collated. The findings discussed in this article confirm that RT/ADT for prostate cancer can significantly impair erectile function. While many men achieve erections through PDE5-I use, others need combined management incorporating exercise and lifestyle modifications, psychosexual counselling and other erectile aids. This article offers a comprehensive treatment algorithm to manage patients with ED associated with RT/ADT. CONCLUSION: Based on published research literature and survey analysis, recommendations are proposed for the standardisation of management strategies employed for ED after RT/ADT. In addition to implementing the algorithm, understanding the rationale for the type and timing of ED management strategies is crucial for clinicians, men and their partners.

Systematic review of live surgical demonstrations and their effectiveness on training.

BACKGROUND: Live surgical demonstrations are commonly performed for surgical conferences. These live procedures have recently come under scrutiny, in particular with issues pertaining to patient safety. This systematic review aimed to explore the evidence for live surgery as a training tool, and to investigate the safety of live surgical broadcasts. METHODS: PubMed, Embase, MEDLINE and Cochrane Library databases were searched using a predefined search strategy from January 1980 to October 2013. Specialty Societies and primary Colleges of Surgeons were searched for guidelines or position statements on live surgical teaching. RESULTS: Educational value criteria demonstrated for live surgery included feasibility, acceptability, construct and concurrent validity. Complication rates during live procedures were not compromised in the majority of studies. Patient safety, however, may be affected during live procedures as success rates have been found to be lower in some studies. Only Cardiothoracic, Urology and Vascular Surgical Societies currently offer guidelines on conducting live surgical demonstrations. CONCLUSION: Little evidence exists on the safety and educational value of live surgery, with few studies of high quality conducted. Guidance on live procedures is scarce, with only three major surgical specialties offering any advice. More needs to be done to establish and promote evidence for the value of live surgery demonstrations.

Development of UK recommendations on treatment for post-surgical erectile dysfunction.

AIM: To develop a management strategy (rehabilitation programme) for postsurgical erectile dysfunction (ED) among men experiencing ED associated with treatment of prostate, bladder or rectal cancer that is suitable for use in a UK NHS healthcare context. METHODS: PubMed literature searches of ED management together with a survey of 13 experts in the management of ED from across the UK were conducted. RESULTS: Data from 37 articles and completed questionnaires were collated. The results discussed in this study demonstrate improved objective and subjective clinical outcomes for physical parameters, sexual satisfaction, and rates of both spontaneous erections and those associated with ED treatment strategies. CONCLUSION: Based on the literature and survey analysis, recommendations are proposed for the standardisation of management strategies employed for postsurgical ED.

The addition of the surgical robot to skin cancer management.

We present the introduction of the surgical robot for pelvic lymphadenectomy for skin cancer through a cross-specialty collaboration. In this prospective series, we include the first report of cases undergoing robot-assisted pelvic lymph node dissection for Merkel cell carcinoma and melanoma in the recognised scientific literature.

Is there a link between BPH and prostate cancer?

BPH is one of the most common diseases of older men, with more than 70% of men over 70 years affected, and prostate cancer is the most common cancer in men in the UK. Prostate cancer generally presents in one of three ways: asymptomatic patients who are screened (usually by a PSA test); men with LUTS who are investigated and undergo prostate biopsy; or patients with symptoms of metastasis such as bone pain. Men can be reassured that the main cause of LUTS is BPH. Only a small proportion of men have LUTS that are directly attributable to prostate cancer. Digital rectal examination (DRE) gives an evaluation of prostate size, which is relevant in particular to BPH management, and along with PSA testing it is one of the only ways of differentiating clinically between BPH and prostate cancer. If a nodular abnormality is present there is around a 50% chance of a diagnosis of prostate cancer being made on biopsy. Raised levels of serum PSA may be suggestive of prostate cancer, but diagnosis requires histological confirmation in almost every case. A normal PSA, PSA density and DRE can give reasonable confidence with regards to excluding clinically significant prostate cancer. BPH is not a known risk factor for prostate cancer, although the two frequently coexist. Age is the strongest predictor of prostate cancer risk, along with family history. BPH is not considered to be a precursor of prostate cancer. It is likely that although BPH may not make prostate cancer more likely to occur, it may increase the chance of diagnosing an incidental cancer.

A dual-centre, cohort comparison of open, laparoscopic and robotic-assisted radical cystectomy.

INTRODUCTION: The role of minimally invasive radical cystectomy as opposed to open surgery for bladder cancer is not yet established. We present comparative outcomes of open, laparoscopic and robotic-assisted radical cystectomy MATERIAL AND METHODS: Prospective cohort comparison of 158 patients from 2003-2008 undergoing open radical cystectomy (ORC) (n = 52), laparoscopic radical cystectomy (LRC) (n =58) or robotic-assisted radical cystectomy (RARC) (n = 48) performed by a team of three surgeons at two hospitals. Peri-operative data, complication rates, length of hospital stay, oncological outcome (including lymph node status) and survival were recorded. Statistical analyses were adjusted to account for potential confounding factors such as ASA grade, gender, age, diversion type and final histology. RESULTS: RARC took longer than LRC and ORC. Patients were about 30 times more likely to have a transfusion if they had ORC than if they had RARC (p < 0.0001) and about eight times more likely to have a transfusion if they had LRC compared with RARC (p < 0.006). Patients were four times more likely to have a transfusion if they had ORC as compared with LRC (p < 0.007). Patients were four times more likely to have complications if they had ORC than RARC (p = 0.006) and about three times more likely to have complications with LRC than with RARC (p = 0.02). Hospital stay was mean 19 days after ORC, 16 days after LRC and 10 days after RARC. CONCLUSIONS: Despite study limitations, RARC had the lowest transfusion and complication rates and the shortest length of stay, although taking the longest to perform.

Overcoming the challenges of robot-assisted radical prostatectomy.

Robot-assisted radical prostatectomy (RARP) is the most commonly performed robotic procedure worldwide and is firmly established as a standard treatment option for localised prostate cancer. Part of the explanation for the rapid uptake of RARP is the reported gentler learning curve compared with the challenges of laparoscopic radical prostatectomy (LRP). However, robotic surgery is still fraught with potential difficulties and avoiding complications while on the steepest part of the learning curve is critical. Furthermore, as surgeons progress there is a tendency to take on increasingly complex cases, including patients with difficult anatomy and prior surgery, and these cases present a unique challenge. Significant intra-abdominal adhesions may be identified following open surgery, or dense periprostatic inflammation may be encountered following TURP; large prostate gland size and median lobes may alter bladder neck anatomy, making difficult subsequent urethro-vesical anastomosis. Even experienced robotic surgeons will be challenged by salvage RARP. Approaching these problems in a structured manner allows many of the problems to be overcome. We discuss some of the specific techniques to deal with these potential difficulties and highlight ways to avoid making serious mistakes.

Robot assisted laparoscopic prostatectomy. Striving for Trifecta outcomes in localised prostate cancer.

Radical prostatectomy (RP) is the gold standard treatment for localised prostate cancer and its oncological effectiveness has been demonstrated so far. With no doubt though, RP has significant potential morbidity and the selection of patients who will likely benefit from surgery while minimising the side effects of incontinence and erectile dysfunction is fundamental. Robot-assisted radical prostatectomy allows us to achieve oncological control, early continence and preservation of erectile function all in one. Thus, analysing its role is of utmost importance.

Laparoendoscopic single-site surgery (LESS) prostatectomy--robotic and conventional approach.

This review deals with the preliminary advances in laparoendoscopic single-site surgery (LESS) as applied to prostate surgery including the simple and radical prostatectomy approaches both robot assisted and robot independent. It analyzed current publications based on animal models and human patients. The authors searched published reports in major urological meeting abstracts, Embase and Medline (1966 to 25 August 2008), with no language restrictions. Key word searches included: "prostate", "prostatectomy", "radical", "surgery", "robot", "da Vinci", "scarless", "scar free", "single port/trocar/incision", "intraumbilical", and "transumbilical", "natural orifice transluminal endoscopic surgery" (NOTES), "SILS", "OPUS" and "LESS". The role of LESS prostatectomy with or without robotic aid has been proven to be technically feasible; however, it is important to note that the approach has significant technical challenges. The da Vinci Surgical System allows some of these ergonomic challenges to be obviated with potentially reduced instrument clash, reduced surgeon and assistant fatigue and better precision with target tasking such as performing the vesicourethral anastomosis. Preliminary consensus regarding oncological control is not yet available on a large scale. Currently, no specific advantage of the LESS approach has been convincingly proven apart from the intuitive improvement in cosmesis. The development, and soon to be launched, flexible robotic platforms towards the end of 2010 will usher with it further refinements making the LESS approach to radical prostatectomy potentially more feasible ergonomically and could see the approach gain a more widespread acceptance.

The assessment of surgical competency in the UK.

INTRODUCTION: The assessment of surgical competence is a vital component of the surgical training process, the accreditation of specialists, and the maintenance of public confidence in the surgical profession [Grantcharov TP, Bardram L, Funch-Jensen P, Rosenberg J. Assessment of technical surgical skills. Eur J Surg 2002;168:139-44.]. The introduction of the Calman system, the European Working Time Directive, the Hospital at Night project, and financial pressures to increase productivity has nearly halved the surgical case load that trainees are exposed to. With less time to acquire surgical proficiency, surgeons may be insufficiently skilled at completion of training [Moorthy K, Munz Y, Sarker SK, Darzi A. Objective assessment of technical skills in surgery. BMJ 2003;327:1032-7.]. We look at the current methods of assessing surgical competency and what new innovative methods are on the horizon. METHODS: A Medline search was performed in April 2005 using the keywords 'surgical training', 'surgical competence', 'surgical simulation' and 'virtual reality'. Only papers published in English have been cited in this review. Articles were reviewed for relevance, impact within the field, and applicability to the UK training system. RESULTS: A large number of articles explore the potential of training techniques - including wet and dry laboratories, computer simulators and virtual reality trainers - to complement traditional 'apprenticeship' surgical training. All of the methods demonstrate the ability to distinguish surgeons of varying competence. DISCUSSION: The advantages of the training methods discussed are many and there is great enthusiasm for introducing skills assessment within a nationally standardised and validated surgical curriculum [Aggarwal R, Moorthy K, Darzi A. Laparoscopic skills training and assessment. Br J Surg 2004;91:1549-58.], as well as using it as an adjunct to traditional methods of training.

Robotic renal surgery.

Robotic surgery is being increasingly used for prostatectomy. Its use in renal surgery has been limited by a perception that it does not offer any extra benefit. This article explores the use of robot assistance in renal surgery. Extensive literature search undertaken using Medline and PubMed. The following keywords were used during the search: robot, robotic, kidney, renal, nephrectomy, partial nephrectomy, pyeloplasty. Relevant articles were extracted and data from these articles presented in the review. Comments on relevant aspects of either technique or results are provided. Apart from initial feasibility studies, little has been published on robot assisted laparoscopic nephrectomy (RALN) for diseased kidneys. Most of the cases of RALN has been carried out in live donors for renal transplantation in a few enthusiastic centres. Experience with robot assisted laparoscopic pyeloplasty (RALP) is more mature. Robot assisted laparoscopic partial nephrectomy (RALPN) is continuing to evolve. Robotic NOTES is currently experimental. Robot assistance seems to have a role in reconstructive renal procedures such as pyeloplasty and partial nephrectomy, due mainly to the precise suturing ability.

Ablative and reconstructive robotic-assisted laparoscopic renal surgery.

INTRODUCTION: The increasing role of robotic technology to facilitate surgical procedures has attracted much attention from surgeons and patients alike. In particular, the dramatic increase in the number of laparoscopic radical prostatectomies performed using the da Vinci surgical system has led to interest in using this technology for other procedures. We have evaluated our own experience performing ablative and reconstructive laparoscopic renal surgery using the da Vinci system to determine its potential role. AIMS: To review our experience of robotic-assisted laparoscopic procedures of the upper urinary tract. MATERIALS AND METHODS: Our da Vinci system was installed in June 2004. A prospective database has been maintained concerning all patients and procedures performed from that time. Procedures involving the upper urinary tract were identified and the data was examined. This included patient demographics, operative time, blood loss, hospital stay and patient outcomes. RESULTS: Twenty-six robotic procedures involved the upper urinary tract. Of these, two had to be converted to conventional laparoscopic surgery because of da Vinci mechanical failure. Robotic-assisted procedures included pyeloplasty (n = 15), simple nephrectomy (n = 2), radical nephrectomy (n = 1), nephroureterectomy (n = 2), and live donor nephrectomy (n = 4). The mean operative time was 215 min. The anastomotic time for the pyeloplasties averaged 47 min. The mean blood loss was 75 ml. There were no conversions to open surgery. The complication rate was 8.7%. Postoperative stay averaged 2.9 days. CONCLUSION: The da Vinci surgical system may be safely used to assist in the performance of laparoscopic renal surgery.