Introduction of robot-assisted radical cystectomy within an established enhanced recovery programme.

OBJECTIVES: To describe the implementation phase of a robot-assisted radical cystectomy (RARC) programme including side-effect profiles and impact on length of stay (LOS). PATIENTS AND METHODS: In all, 114 consecutive patients (82% male) underwent RARC and urinary diversion between April 2013 and December 2015 [ileal conduit (97 patients) and orthotopic neobladder (17)]. Surgery was performed by two surgeons within a designated regional cancer centre. No exclusion criteria were applied. All patients were managed on the Exeter Enhanced Recovery Pathway (ERP) in a unit where embedded enhanced recovery practice was already established. Data were collected prospectively on the national cystectomy registry - the British Association of Urological Surgeons (BAUS) Complex Operations Dataset. RESULTS: RARC was technically feasible in all but one case. The mean operating time was 3-5 h with an overall transfusion rate of 8.8%. There were higher-grade complications (Clavien-Dindo grade III-IV) in 18.4% of patients, with a 30-day mortality rate of 0.9%. The median (range) LOS after RARC was 7 (3-68) days, with a re-admission rate of 18.4%. CONCLUSIONS: The present series shows that RARC can be safely implemented in a unit experienced in robot-assisted surgery (RAS). Case-selection in this setting is not deemed necessary. There are benefits in terms of lower transfusion rates and reduced LOS. The side-effect profile appears to differ from that of open RC, and despite the fact that complication rate is equivalent; 'technical' complications are over-represented in the RAS group. As such, they should improve with experience, recognition, and modification of surgical technique. ERPs can be safely applied to all patients undergoing RARC to maximise the benefits of minimally invasive surgery.

Robotically assisted laparoscopy benefits surgical performance under stress.

While the benefits of robotic surgery for the patient have been relatively well established, little is known about the benefits for the surgeon. This study examined whether the advantages of robotically assisted laparoscopy (improved dexterity, a 3-dimensional view, reduction in tremors, etc.) enable the surgeon to better deal with stressful tasks. Subjective and objective (i.e. cardiovascular) responses to stress were assessed while surgeons performed on either a robotic or conventional laparoscopic system. Thirty-two surgeons were assigned to perform a surgical task on either a robotic system or a laparoscopic system, under three stress conditions. The surgeons completed self-report measures of stress before each condition. Furthermore, the surgeons' cardiovascular responses to stress were recorded prior to each condition. Finally, task performance was recorded throughout each condition. While both groups reported experiencing similar levels of stress, compared to the laparoscopic group, the robotic group displayed a more adaptive cardiovascular response to the stress conditions, reflecting a challenge state (i.e. higher blood flow and lower vascular resistance). Furthermore, despite no differences in completion time, the robotic group performed the tasks more accurately than the laparoscopic group across the stress conditions. These results highlight the benefits of using robotic technology during stressful situations. Specifically, the results show that stressful tasks can be performed more accurately with a robotic platform, and that surgeons' cardiovascular responses to stress are more favourable. Importantly, the 'challenge' cardiovascular response to stress displayed when using the robotic system has been associated with more positive long-term health outcomes in domains where stress is commonly experienced (e.g. lower cardiovascular disease risk).

Robotic technology results in faster and more robust surgical skill acquisition than traditional laparoscopy.

Technical surgical skills are said to be acquired quicker on a robotic rather than laparoscopic platform. However, research examining this proposition is scarce. Thus, this study aimed to compare the performance and learning curves of novices acquiring skills using a robotic or laparoscopic system, and to examine if any learning advantages were maintained over time and transferred to more difficult and stressful tasks. Forty novice participants were randomly assigned to either a robotic- or laparoscopic-trained group. Following one baseline trial on a ball pick-and-drop task, participants performed 50 learning trials. Participants then completed an immediate retention trial and a transfer trial on a two-instrument rope-threading task. One month later, participants performed a delayed retention trial and a stressful multi-tasking trial. The results revealed that the robotic-trained group completed the ball pick-and-drop task more quickly and accurately than the laparoscopic-trained group across baseline, immediate retention, and delayed retention trials. Furthermore, the robotic-trained group displayed a shorter learning curve for accuracy. The robotic-trained group also performed the more complex rope-threading and stressful multi-tasking transfer trials better. Finally, in the multi-tasking trial, the robotic-trained group made fewer tone counting errors. The results highlight the benefits of using robotic technology for the acquisition of technical surgical skills.

Surgeons' display reduced mental effort and workload while performing robotically assisted surgical tasks, when compared to conventional laparoscopy.

BACKGROUND: Research has demonstrated the benefits of robotic surgery for the patient; however, research examining the benefits of robotic technology for the surgeon is limited. This study aimed to adopt validated measures of workload, mental effort, and gaze control to assess the benefits of robotic surgery for the surgeon. We predicted that the performance of surgical training tasks on a surgical robot would require lower investments of workload and mental effort, and would be accompanied by superior gaze control and better performance, when compared to conventional laparoscopy. METHODS: Thirty-two surgeons performed two trials on a ball pick-and-drop task and a rope-threading task on both robotic and laparoscopic systems. Measures of workload (the surgery task load index), mental effort (subjective: rating scale for mental effort and objective: standard deviation of beat-to-beat intervals), gaze control (using a mobile eye movement recorder), and task performance (completion time and number of errors) were recorded. RESULTS: As expected, surgeons performed both tasks more quickly and accurately (with fewer errors) on the robotic system. Self-reported measures of workload and mental effort were significantly lower on the robotic system compared to the laparoscopic system. Similarly, an objective cardiovascular measure of mental effort revealed lower investment of mental effort when using the robotic platform relative to the laparoscopic platform. Gaze control distinguished the robotic from the laparoscopic systems, but not in the predicted fashion, with the robotic system associated with poorer (more novice like) gaze control. CONCLUSIONS: The findings highlight the benefits of robotic technology for surgical operators. Specifically, they suggest that tasks can be performed more proficiently, at a lower workload, and with the investment of less mental effort, this may allow surgeons greater cognitive resources for dealing with other demands such as communication, decision-making, or periods of increased complexity in the operating room.

Robot-assisted laparoscopic prostatectomy versus open: comparison of the learning curve of a single surgeon.

BACKGROUND AND PURPOSE: Because of the increased use of robot-assisted laparoscopic prostatectomy (RALP) for the management of localized prostate cancer, surgeons in training face the issues of developing skills in both open surgery and the robotic console. This study compares prospectively the safety and efficacy of the first 50 open radical retropubic prostatectomy (RRP) procedures and the first 50 RALP procedures, performed by the same surgeon in the same institution. PATIENTS AND METHODS: The patients' baseline demographic, clinical, and oncologic parameters were prospectively recorded. The study end points included oncologic outcome, functional outcomes (at 3 months), and perioperative parameters. Complications were classified according to the modified Clavien system. RESULTS: No statistically significant differences were noted between the two groups in terms of preoperative patient characteristics and oncologic parameters. The operative time and mean estimated blood loss were lower in the RALP group (P<0.001), but no statistically significant difference was noted in regard to transfusion rates (P=0.362). Mean hospital stay was lower in the RALP group (P<0.001). The minor (Clavien I+II) and major (Clavien III+IV) complication rates were comparable between the two groups. The overall positive margin (PSM) rates were 20% and 18% for RRP and RALP, respectively (P=0.799), while for pT(3) disease, the PSM rates were 26.1% and 22.2%% for RRP and RALP, respectively (P=0.53). The 3-month continence rates were 88% and 90% for RRP and RALP, respectively (P=0.749). For preoperatively potent patients, 3-month potency rates were comparable between the two groups (60.6% and 62.1% in the RRP and the RALP group, respectively, P=0.893). CONCLUSION: The early learning curve for RALP appears safe and results in equivalent functional and oncologic outcome, when compared with the results of open surgery.

The Role of Non-Steroidal Anti-Inflammatory Drugs in Renal Colic.

NSAIDs provide optimal analgesia in renal colic due to the reduction in glomerular filtration and renal pelvic pressure, ureteric peristalsis and ureteric oedema. Prevention of glomerular afferent arteriolar vasodilatation renders these patients at risk of renal impairment. NSAIDs have the additional benefit of reducing the number of new colic episodes and preventing subsequent readmission to hospital. Despite recent work promoting the use of pharmacological agents to improve stone passage rates, NSAIDs do not appear to reduce the time to stone passage or increase the likelihood of stone passage in renal colic.

Changing treatments for overactive bladder.

Overactive bladder is a common urological diagnosis which is often untreated as patients fail to seek help for this embarrassing problem. Elizabeth Waine and Mark Stott summarise the symptoms and investigations for overactive bladder and provide an overview of the treatments available.

Management of the overactive bladder: a review of pharmacological therapies and methods used by the urological specialist.

Overactive bladder is a common urological diagnosis, which is often untreated as patients fail to seek help for this embarrassing problem. This disorder causes significant lifestyle limitations for the patient and is also expensive as it reduces national productivity and therefore affected patients should be treated. It is simple for primary care providers to make a working diagnosis in this disorder and they should be carrying out simple investigations in order to make the diagnosis. Commencement of therapy should start with conservative measures such as lifestyle modifications including pelvic floor exercises and bladder drill followed by the introduction of pharmacological treatments if necessary. The patient should be fully educated about their disorder and about the potential side effects of the medication they are given in order to improve compliance. There are a number of antimuscarinics available on the market for the treatment of overactive bladder but it is often difficult to decide which is the best form of management for these patients. In this review we address the necessary investigations that need to be carried out as well as providing an overview of the different non-surgical and medical treatments for this common problem. Should these therapies fail, then the referral to a urological specialist should be made prior to invasive therapy.

VEGF165b, an inhibitory vascular endothelial growth factor splice variant: mechanism of action, in vivo effect on angiogenesis and endogenous protein expression.

Growth of new blood vessels (angiogenesis), required for all tumor growth, is stimulated by the expression of vascular endothelial growth factor (VEGF). VEGF is up-regulated in all known solid tumors but also in atherosclerosis, diabetic retinopathy, arthritis, and many other conditions. Conventional VEGF isoforms have been universally described as proangiogenic cytokines. Here, we show that an endogenous splice variant, VEGF(165)b, is expressed as protein in normal cells and tissues and is circulating in human plasma. We also present evidence for a sister family of presumably inhibitory splice variants. Moreover, these isoforms are down-regulated in prostate cancer. We also show that VEGF(165)b binds VEGF receptor 2 with the same affinity as VEGF(165) but does not activate it or stimulate downstream signaling pathways. Moreover, it prevents VEGF(165)-mediated VEGF receptor 2 phosphorylation and signaling in cultured cells. Furthermore, we show, with two different in vivo angiogenesis models, that VEGF(165)b is not angiogenic and that it inhibits VEGF(165)-mediated angiogenesis in rabbit cornea and rat mesentery. Finally, we show that VEGF(165)b expressing tumors grow significantly more slowly than VEGF(165)-expressing tumors, indicating that a switch in splicing from VEGF(165) to VEGF(165)b can inhibit tumor growth. These results suggest that regulation of VEGF splicing may be a critical switch from an antiangiogenic to a proangiogenic phenotype.