Structured learning for robotic surgery utilizing a proficiency score: a pilot study.

PURPOSE: We evaluated feasibility and benefit of implementing structured learning in a robotics program. Furthermore, we assessed validity of a proficiency assessment tool for stepwise graduation. METHODS: Teaching cases included robotic radical prostatectomy and partial nephrectomy. Procedure steps were categorized: basic, intermediate, and advanced. An assessment tool ["proficiency score" (PS)] was developed to evaluate ability to safely and autonomously complete a step. Graduation required a passing PS (PS ≥ 3) on three consecutive attempts. PS and validated global evaluative assessment of robotic skills (GEARS) were evaluated for completed steps. Linear regression was utilized to determine postgraduate year/PS relationship (construct validity). Spearman's rank correlation coefficient measured correlation between PS and GEARS evaluations (concurrent validity). Intraclass correlation (ICC) evaluated PS agreement between evaluator classes. RESULTS: Twenty-one robotic trainees participated within the pilot program, completing a median of 14 (2-69) cases each. Twenty-three study evaluators scored 14 (1-60) cases. Over 4 months, 229/294 (78 %) cases were designated "teaching" cases. Residents completed 91 % of possible evaluations; faculty completed 78 %. Verbal and quantitative feedback received by trainees increased significantly (p = 0.002, p < 0.001, respectively). Average PS increased with PGY (post-graduate year) for basic and intermediate steps (regression slopes: 0.402 (p < 0.0001), 0.323 (p < 0.0001), respectively) (construct validation). Overall, PS correlated highly with GEARS (ρ = 0.81, p < 0.0001) (concurrent validity). ICC was 0.77 (95 % CI 0.61-0.88) for resident evaluations. CONCLUSION: Structured learning can be implemented in an academic robotic program with high levels of trainee and evaluator participation, encouraging both quantitative and verbal feedback. A proficiency assessment tool developed for step-specific proficiency has construct and concurrent validity.

Prospective Evaluation of Continence Following Radical Cystectomy and Orthotopic Urinary Diversion Using a Validated Questionnaire.

PURPOSE: We evaluated continence outcomes in male patients undergoing orthotopic neobladder diversion after radical cystectomy using a validated questionnaire. MATERIALS AND METHODS: Using our institutional review board approved bladder cancer database we identified 1,269 patients who underwent open radical cystectomy from 2002 to 2015. Orthotopic neobladder was constructed in 935 (74%) patients, of whom 798 (85%) were male. Beginning in 2012 the patients completed a validated pictorial pad use questionnaire at each followup visit. The questionnaire assessed pad number, size and wetness as well as catheter use. Continence was defined as use of no pads or pads that are almost dry. Questionnaires were stratified into distinct postoperative intervals for analysis. Female patients, or patients with artificial urinary sphincters or prior radiotherapy were excluded from the study. RESULTS: A total of 188 male patients with available questionnaires were followed from September 2012 to August 2015. Overall 447 questionnaires were collected, with 351 interval distinct questionnaires separated into intervals of less than 3, 3 to 6, more than 6 to 12, more than 12 to 18, more than 18 to 36 and more than 36 months after surgery (64, 61, 58, 49, 61 and 58 questionnaires, respectively). Daytime continence increased from 59% at less than 3 months postoperatively to 92% by more than 12 to 18 months. Nighttime continence increased from 28% at less than 3 months postoperatively to 51% by more than 18 to 36 months. Nearly 50% of patients reported daytime and nighttime continence by 18 to 36 months. CONCLUSIONS: After orthotopic neobladder diversion in male patients, continence improves significantly by 6 months and subsequently plateaus with 92% daytime continence by more than 12 to 18 months. Orthotopic neobladder represents an excellent functional option for urinary diversion.

Incisional and Parastomal Hernia following Radical Cystectomy and Urinary Diversion: The University of Southern California Experience.

PURPOSE: Hernia is a common complication following radical cystectomy and urinary diversion. We investigated the clinical and radiological evidence for parastomal and incisional hernias, and their risk factors in a large cohort. MATERIALS AND METHODS: Using an institutional review board approved prospective database we reviewed the records of 1,101 patients who underwent radical cystectomy from 2003 to 2013. Followup (median 57 months) was available for 670 patients. Of the 670 patients 92 underwent ileal conduit diversion using Turnbull stomas with a median followup 34 months. Patients were followed with computerized tomography cancer surveillance. Standardized criteria were used to define parastomal and incisional hernias by an expert radiologist. Multivariate logistic regression was done to identify independent predictors. RESULTS: Parastomal hernia was diagnosed in 21 of 92 patients (23%) with a mean age at diagnosis of 76.5 years. Incisional hernia was present in 125 of 670 patients (18.7%) with a mean age at diagnosis of 68.6 years. Five patients had both hernia types. Of patients with parastomal and incisional hernias 11 (53%) and 111 (88.8%), respectively, were male. Mean body mass index was 27.5 and 27.3 kg/m(2) in patients with parastomal and incisional hernias, respectively. Mean parastomal and incisional defect sizes were 3.8 and 2.4 cm, respectively. In 18 patients (85%) parastomal hernias were clinically and radiologically evident, 5 patients were symptomatic and 2 underwent repair. In 51 patients (40%) incisional hernias were clinically and radiologically evident, 34 were symptomatic and 48 underwent repair. Multivariate logistic regression showed significant associations of incisional hernia with age, gender, incision length, orthotopic diversion and body mass index. Parastomal hernia had no significant association. CONCLUSIONS: Hernia is common after cystectomy and diversion. Age, gender, body mass index, incision length and diversion type are risk factors for incisional hernia. Multi-institutional prospective studies may better identify patients at high risk.

Beyond 2D telestration: an evaluation of novel proctoring tools for robot-assisted minimally invasive surgery.

Experienced surgeons commonly mentor trainees as they move through their initial learning curves. During robot-assisted minimally invasive surgery, several tools exist to facilitate proctored cases, such as two-dimensional telestration and a dual surgeon console. The purpose of this study was to evaluate the utility and efficiency of three, novel proctoring tools for robot-assisted minimally invasive surgery, and to compare them to existing proctoring tools. Twenty-six proctor-trainee pairs completed validated, dry-lab training exercises using standard two-dimensional telestration and three, new three-dimensional proctoring tools called ghost tools. During each exercise, proctors mentored trainees by correcting trainee technical errors. Proctors and trainees completed post-study questionnaires to compare the effectiveness of the proctoring tools. Proctors and trainees consistently rated the ghost tools as effective proctoring tools. Both proctors and trainees preferred 3DInstruments and 3DHands over standard two-dimensional telestration (proctors p < 0.001 and p = 0.03, respectively, and trainees p < 0.001 and p = 0.002, respectively). In addition, proctors preferred three-dimensional vision of the operative field (used with ghost tools) over two-dimensional vision (p < 0.001). Total mentoring time and number of instructions provided by the proctor were comparable between all proctoring tools (p > 0.05). In summary, ghost tools and three-dimensional vision were preferred over standard two-dimensional telestration and two-dimensional vision, respectively, by both proctors and trainees. Proctoring tools-such as ghost tools-have the potential to improve surgeon training by enabling new interactions between a proctor and trainee.

Ureteroenteric Strictures After Open Radical Cystectomy and Urinary Diversion: The University of Southern California Experience.

OBJECTIVE: To evaluate the risk factors, management, and outcomes of benign ureteroenteric strictures (UES) in patients undergoing open radical cystectomy (RC) and urinary diversion for urothelial bladder carcinoma. MATERIALS AND METHODS: Using our institutional review board-approved institutional bladder cancer database, we identified 1964 patients who underwent RC for urothelial bladder carcinoma between 1971 and 2008. Patients underwent a uniform refluxing ureteroenteric anastomosis technique to ileum. In patients with UES, we reviewed clinicopathologic, management, and outcome variables. A multivariate logistic regression model was used to identify independent UES predictors. RESULTS: Forty-nine patients and 51 renal units were retrospectively identified with benign UES (2.6%). Median follow-up was 12.4 years (0.2-27.3 years) and median time from RC to UES diagnosis was 10 months (2 months-10 years). Although one-third were asymptomatic, common presentations included flank pain (22%) and urinary tract infection (9%). Thirty-one patients underwent primary endoscopic treatments, including dilatation and stenting, of whom, 13 patients (42%) underwent secondary endoscopic treatment and 9 patients (29%) underwent open revision. Three patients underwent primary open management. Median glomerular filtration rate did not change after management (49-48 mL/min); however, imaging showed improvement in 50% of cases. A multivariate logistic regression model revealed no association with age, body mass index, Charlson comorbidity index, perioperative radiation or chemotherapy, or preoperative serum albumin in predicting UES. CONCLUSION: Benign UES are uncommon after RC and urinary diversion using a consistent meticulous surgical approach. More commonly on the left, UES generally present a few months after RC. Although no specific predisposing factor was determined, surgical technique plays an important role.

Development and Validation of a Novel Robotic Procedure Specific Simulation Platform: Partial Nephrectomy.

PURPOSE: We developed a novel procedure specific simulation platform for robotic partial nephrectomy. In this study we prospectively evaluate its face, content, construct and concurrent validity. MATERIALS AND METHODS: This hybrid platform features augmented reality and virtual reality. Augmented reality involves 3-dimensional robotic partial nephrectomy surgical videos overlaid with virtual instruments to teach surgical anatomy, technical skills and operative steps. Advanced technical skills are assessed with an embedded full virtual reality renorrhaphy task. Participants were classified as novice (no surgical training, 15), intermediate (less than 100 robotic cases, 13) or expert (100 or more robotic cases, 14) and prospectively assessed. Cohort performance was compared with the Kruskal-Wallis test (construct validity). Post-study questionnaire was used to assess the realism of simulation (face validity) and usefulness for training (content validity). Concurrent validity evaluated correlation between virtual reality renorrhaphy task and a live porcine robotic partial nephrectomy performance (Spearman's analysis). RESULTS: Experts rated the augmented reality content as realistic (median 8/10) and helpful for resident/fellow training (8.0-8.2/10). Experts rated the platform highly for teaching anatomy (9/10) and operative steps (8.5/10) but moderately for technical skills (7.5/10). Experts and intermediates outperformed novices (construct validity) in efficiency (p=0.0002) and accuracy (p=0.002). For virtual reality renorrhaphy, experts outperformed intermediates on GEARS metrics (p=0.002). Virtual reality renorrhaphy and in vivo porcine robotic partial nephrectomy performance correlated significantly (r=0.8, p <0.0001) (concurrent validity). CONCLUSIONS: This augmented reality simulation platform displayed face, content and construct validity. Performance in the procedure specific virtual reality task correlated highly with a porcine model (concurrent validity). Future efforts will integrate procedure specific virtual reality tasks and their global assessment.