ROBOTICS AND UROLOGY. 2/5 ABSTRACTS MEETING OF THE AMERICAN UROLOGICA

Saturday, May 17, 2014 1:00 PM-3:00 PM
OCCC: W 311 A
General & Epidemiological Trends & Socioeconomics: Quality of Life
Funding: None
MP15-05: HEALTH RELATED QUALITY OF LIFE FROM A PROSPECTIVE RANDOMIZED CLINICAL TRIAL OF ROBOTIC ASSISTED LAPAROSCOPIC VERSUS OPEN RADICAL CYSTECTOMY 
Jamie Messer*, Louisville, KY, John Fitzgerald, Stony Brook, NY, Robert Svatek, San Antonio, TX, Dipen Parekh, Miami, FL

Abstract: MP15-05
Introduction and Objectives
Robotic Assisted Laparoscopic Radical Cystectomy (RARC) has been reported with potential benefits compared to the traditional Open Radical Cystectomy (ORC), though to date no study has compared health related quality of life (HRQOL) outcomes between ORC and RARC in a prospective randomized fashion.Methods
Prospective Randomized Clinical trial evaluating the HRQOL using the FACT-VCI for ORC versus RARC in consecutive patients from July 2009 to June 2011.Results
To date 47 patients had met inclusion criteria, with 40 patients being randomized for analysis. The groups consisted of 20 ORC and 20 RARC, each similar with regards to age, sex, race, BMI, comorbidities (ASA), previous abdominal procedures, type of urinary diversion, perioperative chemotherapy, length of stay, and final pathologic stage. We administered the FACT-VCI HRQOL preoperatively and then at 3, 6, 9, and 12 months postoperatively. We noted a return to baseline at 3 months postoperatively in all measured domains with no statistically significant difference between the robotic and open groups.Conclusions
There are no differences in the HRQOL outcomes between ORC and RARC with return of quality of life to baseline 3 months after radical cystectomy.Date & Time: May 17, 2014 1:00 PM-3:00 PM
Session Title: General & Epidemiological Trends & Socioeconomics: Quality of Life
Sources of Funding: None

 

Saturday, May 17, 2014 1:00 PM-3:00 PM
OCCC: W 311 A
General & Epidemiological Trends & Socioeconomics: Quality of Life
Funding: The Weinbaum Family Prostate Cancer Prevention Fund of The Prostate Centre at Princess Margaret Cancer Centre
MP15-06: Health-Related Quality of Life in Robotic versus Open Radical Prostatectomy: First Report 
Stacy Rush*, Shabbir MH Alibhai, Lizhen Xu, Wei Xu, Alyssa S Louis, Andrew G Matthew, Michael Nesbitt, Antonio Finelli, Neil E Fleshner, Robert Hamilton, Girish Kulkarni, Alexandre Zlotta, Michael AS Jewett, John Trachtenberg, Toronto, Canada

Abstract: MP15-06
Introduction and Objectives
Despite growing use of robot-assisted laparoscopic radical prostatectomy (RARP), it is unclear if health-related quality of life (HRQoL) outcomes are superior to open prostatectomy (ORP).Methods
We retrospectively analyzed records from men who received ORP or RARP at our institution as their primary therapy for prostate cancer between January 2009 and December 2012. Patients completed a demographics questionnaire and the Patient-Oriented Prostate Utility Scale (PORPUS), a validated disease-specific HRQoL instrument prior to surgery and every 3 months up to 15 months after surgery.Results
A total of 974 men met the inclusion criteria, 643 ORP and 331 RARP patients. At baseline, RARP patients were significantly younger (p<0.001), had lower body mass index (p<0.001), lower pre-operative prostate-specific antigen (PSA) (p<0.001), fewer comorbidities (p<0.004) and higher baseline PORPUS scores (p=0.024). On follow-up, unadjusted PORPUS scores were significantly higher in the RARP group at each point. However, on multivariable analysis adjusting for age, type of procedure (ORP vs. RARP), Gleason score, BMI, first PSA, comorbidity, ethnicity , and baseline PORPUS scores, PORPUS score was higher for the RARP group at 3 months (p=0.031) and 9 months (p=0.002), but not at 6, 12 or 15 months. No difference was greater than the minimum clinically significant difference.Conclusions
Though HRQoL outcomes appear improved with RARP, these differences are not clinically important and are likely accounted for by baseline differences in patient selection. Further comparative studies and randomized trials are needed to assess whether one treatment option provides consistently better HRQOL outcomes.Date & Time: May 17, 2014 1:00 PM-3:00 PM
Session Title: General & Epidemiological Trends & Socioeconomics: Quality of Life
Sources of Funding: The Weinbaum Family Prostate Cancer Prevention Fund of The Prostate Centre at Princess Margaret Cancer Centre

Table 1: Baseline demographics of study patients
Factors Open Robotic p-value
Age (Years) N 643 331
Mean (sd) 61.49(7.07) 59.71(7.03) <0.001
First Elevated PSA N 432 195
Mean (sd) 7.58 (5.22) 5.89 (3.28) <0.001
BMI N 597 299
Mean (sd) 28.6 (4.0) 27.3 (3.6) <0.001
Charlson comorbidity score 0 512 (80) 289 (87)
> = 1 131 (20) 42 (13) 0.004
Biopsy Gleason Score N (%) Low/Intermediate risk: Gleason 4, 5, 6, or 7 532 (88) 310 (99)
High risk: Gleason 8, 9, 10 76 (12) 4 (1) <0.001
Ethnicity Caucasian: n(%) 228 (75) 98 (63)
Non Caucasian n(%) 75 (25) 58 (37) 0.008
PORPUS-P Score N 437 210
Mean (sd) 82.59(11.10) 84.73(11.26) 0.024
Nerve Sparing Status None: n (%) 155 (25) 19 (7)
Unilateral: n (%) 146 (23) 45 (15)
Bilateral: n (%) 326 (52) 224 (78) <0.001
Table 2: Univariate predictors of baseline (pre-operative) PORPUS-P
Variable Effect Confidence Interval p-value
Age -0.22 (-0.34,-0.105) <0.001
Type of RP* 2.14 (0.30,3.98) 0.023
Gleason Score -4.35 (-7.33,-1.37) 0.004
BMI -0.025 (-0.26,0.21) 0.836
First Positive PSA -0.24 (-0.44, -0.04) 0.017

 

Saturday, May 17, 2014 1:00 PM-3:00 PM
OCCC: W 311 A
General & Epidemiological Trends & Socioeconomics: Quality of Life
Funding: The Weinbaum Family Prostate Cancer Prevention Fund of The Prostate Centre at Princess Margaret Hospital and the Princess Margaret Cancer Centre Foundation.
MP15-08: Quality of Life Following Focal Therapy, Active Surveillance and Robotic Prostatectomy for Localized Prostate Cancer 
Alyssa Louis*, Toronto, Canada, Stacy Rush, , , Shabbir Alibhai, Andrew Matthew, Robin Kalnin, Michael Nesbitt, Richard Walker, Manjula Maganti, Antonio Finelli, Neil Fleshner, Michael Jewett, Alexandre Zlotta, Girish Kulkarni, Robert Hamilton, John Trachtenberg, Toronto, Canada

Abstract: MP15-08
Introduction and Objectives
Robot assisted radical prostatectomy (RARP) has rapidly become the standard of care for localized prostate cancer when active treatment is favored over active surveillance (AS). Recently, ablation of the index lesion with focal therapy (FT) has been developed in an attempt to reduce surgical morbidity. Here we compare these three contemporary techniques of cancer control in low volume, low and intermediate risk localized prostate cancers to evaluate health related quality of life (HRQoL) outcomes.Methods
We analyzed records of men treated with RARP, FT or AS for localized prostate cancer at the University Health Network between 2006-2012. Clinical and demographic variables and HRQoL data were collected pre intervention and sequentially thereafter with the Patient Oriented Prostate Utility Scale (PORPUS), the International Index of Erectile Function (IIEF) and the International Prostate Symptom Score (IPSS). Treatment groups were propensity-matched for important predictors of HRQoL. Our primary outcome was HRQoL at one year after treatment or date of enrolment to AS.Results
Prior to matching, there were 367 RARP, 52 FT and 504 AS patients. The groups differed in age, disease risk, comorbidity, ethnicity, baseline IPSS, and baseline PORPUS (p<0.05). On univariate analysis, significant differences were detected in PORPUS, IIEF and IPSS, with AS and FT showing improved outcomes over RARP at one year (p<0.05). On multivariable analysis, significantly lower HRQoL was associated with RARP, older age and lower baseline PORPUS (p<0.05). After matching for age, disease risk, and baseline HRQoL, 41 AS, and 44 RARP patients were compared 41 and 44 FT patients respectively. No statistically significant differences were detected between the 3 groups in IIEF, IPSS or PORPUS at one year.Conclusions
These results suggest that patient selection bias may contribute to HRQoL outcomes to a greater degree than treatment strategy. When matched for baseline differences, we found no statistically significant differences in overall HRQoL, erectile function, and prostate symptomatology at one year after treatment, however this result may be confounded by small sample size and warrants validation with more individuals.Date & Time: May 17, 2014 1:00 PM-3:00 PM
Session Title: General & Epidemiological Trends & Socioeconomics: Quality of Life
Sources of Funding: The Weinbaum Family Prostate Cancer Prevention Fund of The Prostate Centre at Princess Margaret Hospital and the Princess Margaret Cancer Centre Foundation.

Focal Therapy n=41 Active Surveillance n=41
One year IIEF (n=19) 20.4 ± 4.6 20.0 ± 5.1 p=0.78
One year IPSS (n=21) 7.9 ± 6 7.2 ± 5.3 p=0.93
One year PORPUS Psychometric (n=22) 87.9 ± 10.2 84.7 ± 11.4 p=0.76
Focal Therapy n=44 Robot Assisted Radical Prostatectomy n=44
One year IIEF (n=20) 20.3 ± 4.5 11 ± 5.8 p=0.06
One year IPSS (n=21) 7.9 ± 6 4.8 ± 3.6 p=0.65
One year PORPUS Psychometric (n=23) 88.1 ± 10 80.2 ± 10.4 p=0.2

 

Saturday, May 17, 2014 1:00 PM-3:00 PM
OCCC: W 311 A
General & Epidemiological Trends & Socioeconomics: Quality of Life
Funding: None
MP15-11: Age-stratified Return of Urinary and Sexual Function Following Radical Prostatectomy: Older Men Do Not Do Worse 
J Joy Lee*, Shufeng Li, John Leppert, Benjamin Chung, Stanford, CA

Abstract: MP15-11
Introduction and Objectives
At 2 years following radical prostatectomy (RP), approximately 60% of men have the “trifecta” of complete urinary continence, normal sexual potency, and no evidence of disease. Older men have been thought to have inferior functional outcomes compared to younger men, but what is not clear is if this is purely a result of age, or whether objective and subjective urinary and sexual function can be explained by different pre-operative baselines and varying rates of recovery. We sought to elucidate the effect of age on the rate of return to baseline for urinary and sexual function.Methods
Between 2006-2012, 263 men who underwent RP at a single institution filled out the Expanded Prostate cancer Index Composite (EPIC) questionnaire, a validated health-related quality of life survey. Patients completed surveys regarding urinary and sexual function pre-operatively, as well as at 3, 6, 12 and 24 months following RP. Primary outcome was the percentage of baseline achieved at each time point for both urinary and sexual domains. We evaluated age as a categorical variable. Baseline patient and tumor characteristics were analyzed, and generalized linear mixed effects regression models were employed to evaluate age as an independent predictor of return to baseline over time. The Bonferroni correction was used to adjust for multiple pairwise comparisons.Results
Older and younger men had similar pre-operative baseline scores in urinary function, though older men had lower pre-operative sexual scores. In the urinary domain, type of surgery (open versus robotic) and visit (3, 6, 12, or 24 months post-operatively) had a significant effect on return to baseline, though age and nerve-sparing status had no impact. By 24 months, all age groups had attained >90% of baseline, and there was no difference based on age. In the sexual domain, type of surgery, visit, and nerve-sparing status were significant, while age was not. By 24 months, although the youngest age group had reached 69.3% of baseline compared to 57.1% in the oldest group, this was not significantly different.Conclusions
Age was not a predictor of return of urinary and sexual function in our cohort when men were compared against their own pre-operative baselines. In contrast to the belief that increasing age portends a worse outcome, our data suggests that when matched for pre-operative baseline function, age does not affect recovery of urinary and sexual function.Date & Time: May 17, 2014 1:00 PM-3:00 PM
Session Title: General & Epidemiological Trends & Socioeconomics: Quality of Life
Sources of Funding: None

 

Saturday, May 17, 2014 1:00 PM-3:00 PM
OCCC: W 311 A
General & Epidemiological Trends & Socioeconomics: Quality of Life
Funding: None
MP15-12: The impact of surgical caseload volume on quality of life in men after robot-assisted radical prostatectomy 
Brian Kim*, Madhur Merchant, Jeff Slezak, Kimberly Porter, Joy Gelfond, Steven J. Jacobsen, Gary W. Chien, Los Angeles, CA

Abstract: MP15-12
Introduction and Objectives
Increased robotic surgical volumes correlate to better peri-operative outcomes, such as reduced positive surgical margin rates (PSMRs). The impact of surgeon experience on long-term cancer-specific and functional outcomes is less evident. The study objective was to evaluate whether caseload volume for robot-assisted radical prostatectomy (RARP) impacts quality of life in prostate cancer patients.Methods
From March 2011 to September 2013, we enrolled men who underwent a RARP within the Kaiser Permanente Southern California Healthcare system. All surgeons with robotic privileges had undergone a rigorous credentialing process and had extensive training in robotics in fellowship and/or residency. Patients completed the Expanded Prostate Cancer Index Composite (EPIC)-26, a validated quality of life survey, at baseline (time of diagnosis) and at 1, 3, 6, 12, 18, and 24 months following surgery. EPIC-26 scores were then compared between “low-volume” surgeons (who completed <100 career RARPs) and “high-volume” surgeons (who completed ≥100 career RARPs) using the Chi-squared and Wilcoxon Rank-Sum tests. RARPs were performed using a standard 6-port transperitoneal approach with one console surgeon and one assistant surgeon.Results
A total of 1675 men underwent a RARP during the study period. Fifteen low- and 10 high-volume urologists performed 1082 and 593 RARPs respectively as the console surgeon. The average number of RARPs performed was 15.9 in the low- and 146.7 in the high-volume groups. High-volume surgeons assisted the majority of low-volume surgeons in their respective cases. Patients were similar in clinico-pathological traits, apart from older men in the high-volume group (61.3 vs. 60.8 years, p=0.035). High-volume group patients had less intra-operative blood loss (97.0 vs 136.8 mL, p<0.0001) and underwent more bladder-neck reconstructions (253 vs. 237 cases, p<0.0001). PSMRs were similar for high- and low-volume surgeons (21.3% vs. 24.4%, p=0.2). There were no differences in EPIC-26 scores thoughout the entire 24-month follow-up period.Conclusions
Surgical volume did not appear to impact quality of life in men who underwent RARP after 2 years follow-up. In our robotics program, high-volume surgeons may have acted as proctors in low-volume surgeons’ cases, positively influencing peri-operative and long-term outcomes. These results support the benefit of having experienced assistants, in order to assure equal outcomes, not at the expense of excluding lower-volume credentialed surgeons.Date & Time: May 17, 2014 1:00 PM-3:00 PM
Session Title: General & Epidemiological Trends & Socioeconomics: Quality of Life
Sources of Funding: None

 

Saturday, May 17, 2014 1:00 PM-3:00 PM
OCCC: W 307
Technology & Instruments: Surgical Education & Skills Assessment II
Funding: none
MP14-02: Development of novel intraoperative telementoring system for robot-assisted radical prostatectomy: a feasible impact on the learning curve 
Nobuyuki Hinata*, Hideaki Miyake, Masato Fujisawa, Kobe, Japan

Abstract: MP14-02
Introduction and Objectives
To develop a web-based audiovisual telementoring system for robot-assisted radical prostatectomy (RARP) and to assess the utility of this system.Methods
A telementoring system for RARP, consisting of three-dimensional high definition view of the operating field, overview of the operating room, annotation function and two-channel audio feed with bidirectional connectivity between two institutions, was developed. The outcomes of RARP performed for the initial 30 patients by two surgeons with telementoring were compared with those with direct mentoring.Results
This system was shown to function properly with an acceptable latency. There were no significant differences in several parameters reflecting surgical outcomes, including the operating time, complication rate, early continence status and positive margin rate, between the telementoring and direct mentoring groups.Conclusions
These findings suggest the usefulness of the telementoring system for promoting the spread of precise surgical techniques associated with RARP. To our knowledge, this is the first report concerning the telementoring for robot-assisted surgery.Date & Time: May 17, 2014 1:00 PM-3:00 PM
Session Title: Technology & Instruments: Surgical Education & Skills Assessment II
Sources of Funding: none

 

Saturday, May 17, 2014 1:00 PM-3:00 PM
OCCC: W 307
Technology & Instruments: Surgical Education & Skills Assessment II
Funding: McMaster University Surgical Associates Education Grant
MP14-03: Validation of an intraoperative assessment tool for evaluating trainees and providing feedback during robot-assisted radical prostatectomy 
Christopher Morris*, Jen Hoogenes, Edward Matsumoto, Ranil Sonnadara, Bobby Shayegan, Hamilton, Canada

Abstract: MP14-03
Introduction and Objectives
As urology training shifts toward competency-based frameworks, valid and reliable methods for high-stakes assessment of trainees are crucial. Standardized evaluation metrics are lacking for robot-assisted radical prostatectomy (RARP). As RARP is becoming the gold standard for treatment of localized prostate cancer, the development and validation of a RARP assessment instrument is timely. We are currently validating a RARP assessment tool for use in the intraoperative setting, with a primary focus on providing feedback throughout the learning curve.Methods
An initial inventory of 13 procedural steps and 60 sub-steps was generated using a modified Delphi technique at McMaster University. We then recruited 13 RARP surgeons from across North America to serve as our expert Delphi panel. Experts anonymously rated each RARP step and sub-step on a 5-point Likert scale of agreement for inclusion in the final assessment tool. Qualitative feedback was elicited to determine appropriate step placement, wording, and suggestions. Responses were compiled, the inventory was edited through three iterations, and 100% consensus was achieved. Intraoperative da Vinci® videos of residents were then recorded as they independently performed the steps of ‘dropping the bladder’ and ‘ligation of the dorsal venous complex’. Five videos each from PGY 3-5 residents and 5 randomly-selected expert videos from our database of RARP cases were edited to include these two steps. Videos have been distributed to our panel of 8 expert RARP surgeons who are serving as raters throughout the validation process. Raters are blinded to level of training and will use the inventory as a guide to assess each step using the validated GEARS tool (Goh, et al.), a procedure-specific checklist, and an overall ‘pass/fail’ rating. Raters will assess 2-4 steps at a time until all steps and sub-steps have been evaluated.Results
Through the Delphi study, steps were decreased by 13% and a skip pattern was incorporated, and there was no attrition until the last round (final N=12). The result was 13 critical steps with 52 sub-steps. The assessment tool will be piloted in our urology program and revisions will be made as necessary.Conclusions
Our team has developed the first comprehensive inventory of RARP steps with excellent expert consensus. A novel, psychometrically sound intraoperative RARP assessment tool that is currently undergoing validation will be incorporated into urology curricula. This instrument has the potential to be used for future credentialing of RARP surgeons.Date & Time: May 17, 2014 1:00 PM-3:00 PM
Session Title: Technology & Instruments: Surgical Education & Skills Assessment II
Sources of Funding: McMaster University Surgical Associates Education Grant

 

Saturday, May 17, 2014 1:00 PM-3:00 PM
OCCC: W 307
Technology & Instruments: Surgical Education & Skills Assessment II
Funding: University of Washington, Department of Urology
MP14-04: Crowd-Sourced Assessment of Technical Skills (C-SATS™): An Adjunct to Urology Resident Simulation Training 
Daniel Holst*, Seattle, WA, Lee White, Palo Alto, CA, Timothy Brand, Tacoma, WA, Jonathan Harper, Thomas Lendvay, Seattle, WA

Abstract: MP14-04
Introduction and Objectives
Objective structured assessment of surgical performances has been shown to predict patient outcomes. The process of reviewing surgical video and grading them is time intensive, expensive and involves recruitment of multiple ‘expert’ surgeons to participate. The lag time for receiving feedback of scores may prohibit its value as a viable method for large numbers of performances. We used crowd-sourcing to obtain valid performance grading of urologic trainees’ and faculty surgical skills performances.Methods
Three urology residents (PGY-2, -4, -5) and two faculty performed a robotic Fundamentals of Laparoscopic Surgery (FLS) intracorporeal suturing module as part of a standard residency training session. These FLS performances were recorded and uploaded to a web-based survey tool that incorporated 3 domains from a validated robotic surgery skills assessment tool (Global Evaluative Assessment of Robotic Surgery – GEARS). Three robotic surgery faculty graded the suturing videos using the GEARS tool and these grades were compared to the grades of 50 Amazon.com Mechanical Turk Project™ crowd workers per video. Composite performance scores were tallied for each group and compared for correlation using Cronbach’s alpha statistical test.Results
It took an average of 2 hours 50 minutes for the five videos to receive 50 Turker grades. The inter-rater reliability (IRR) between the surgeons and crowd was 0.9170 using Cronbach’s Alpha statistical test (CI = 0.2024-0.9194), which indicates an agreement level between the two groups as “excellent.” The linear relationship between the surgeon grades and crowd grades is shown in the attached figure. The crowds were able to discriminate surgical level, however, both the crowds and the faculty rated one senior trainee performance with a higher score than one of the robotic surgeon faculty’s performance.Conclusions
This is the first demonstration of crowdsourcing as a means of assessing surgical skills performance as part of a residency simulation training curriculum. The crowds could discriminate skill and rated the performances with accuracy relative to a panel of faculty raters. The crowds provided rapid feedback and were inexpensive. Future studies expanding the validation of crowd-sourcing as an adjunct to objectively measuring technical skills of trainees are required.Date & Time: May 17, 2014 1:00 PM-3:00 PM
Session Title: Technology & Instruments: Surgical Education & Skills Assessment II
Sources of Funding: University of Washington, Department of Urology

 

Saturday, May 17, 2014 1:00 PM-3:00 PM
OCCC: W 307
Technology & Instruments: Surgical Education & Skills Assessment II
Funding: None
MP14-05: Knowledge-based Activity Recognition during Robot-assisted Surgery: Baby Steps towards Autonomous Surgery 
Ashirwad Chowriappa*, Mohamed Sharif, Syed Johar Raza, Buffalo, NY, Khurshid Guru, East Amherst, NY

Abstract: MP14-05
Introduction and Objectives
Advances in automation are obvious in both automobile and aviation industries. Automated surgical systems are the next frontier for Robot-Assisted Surgery (RAS). Surgical step recognition is the key-maneuver needed for initiating automation during RAS. A novel methodology for the automated detection of surgical activities from intraoperative sequences during RAS is presented.Methods
Activity sequences during RAS were classified and labeled by expert robotic surgeons based on tool and tissue related criteria (i.e. cautery, camera motion, tissue dissection, etc.). Approach for surgical activity recognition that is capable of identifying known activities and distinguish them from unknown activities is developed and implemented. As these activities are spatio-temporally correlated, we use a procedure-centered description in order to extract eight perceptually characteristic features that capture the three-dimensional structures of the surgical activities.Results
The method was validated using 96 expert annotated samples for various surgical activities, extracted from 6 Robot-assisted Radical Prostatectomies (RARP). High (512xn) dimensional feature vectors were extracted frame-wise from activity sequences in RARP. These sequences are warped non-linearly in the time domain to determine the closest sub-sequence match in the surgical procedure using Dynamic Time Warping (DTW). Similar activities tend to cluster within the same region of a multidimensional space in which the axes are the perceptual properties. Closeness between high-dimensional sequences was determined by their Manhattan distance metric (L1 norm). Our results demonstrate that actions of the same activity generate a lower score when compared to activities of a different nature (Figure).Conclusions
Automated activity sequence recognition during RAS paves the way for surgeon-independent procedures.Date & Time: May 17, 2014 1:00 PM-3:00 PM
Session Title: Technology & Instruments: Surgical Education & Skills Assessment II
Sources of Funding: None

 

Saturday, May 17, 2014 1:00 PM-3:00 PM
OCCC: W 307
Technology & Instruments: Surgical Education & Skills Assessment II
Funding: none
MP14-06: Suturing simulation versus robotic practice: an evaluation of performance improvement, content, and face validity in novice operators. 
Samuel M Lindner, Michael J Amirian*, Edouard J Trabulsi, Costas D Lallas, Philadelphia, PA

Abstract: MP14-06
Introduction and Objectives
Virtual reality (VR) simulation has been advocated for improving robotic surgery skills for novice trainees. In the absence of dedicated suturing simulation, however, VR simulation has not translated to increases in real-world suturing performance, and the incremental benefit of VR simulation over dry lab practice is unclear. The aim of this study is to evaluate the effectiveness of VR simulation versus dry lab suturing practice at improving suturing performance in robotic surgery.Methods
Nineteen novice participants with no prior robotic suturing experience were randomized to two groups (VR simulation and dry lab). Each group underwent baseline suturing evaluation using a validated, objective suture score method. Groups were next assigned to train on the Simbionix™ Suturing Module (SSM) or undertake suturing practice using the da Vinci Surgical System in a dry lab. At the conclusion of training or practice, final suturing performance was evaluated using the objective suture scoring method. Participants in the VR simulation group were surveyed at the conclusion of the final suturing evaluation to assess the face and content validity of the SSM.Results
Both groups experienced significant improvement after training (VR simulation group p=0.0078; dry lab group p=0.0039). There was no significant difference in improvement between the two groups after undergoing training with either SSM use or suturing practice using the robotic surgical system in a dry lab. Improvement in composite timing scores were 123 and 172 in the VR simulation and dry lab test groups, respectively (p=0.36). In the validity assessment, participants rejected the face validity of the SSM with regard to simulated tissue behavior, and confirmed face validity for clutching, needle driving, depth/spatial relationship, and visual appearance. The participants confirmed content validity of the SSM in all categories, finding simulated tissue behavior, clutching, needle driving, depth/spatial relationship, and visual appearance useful and relevant for training.Conclusions
In this sample of novice operators, there was no significant advantage to training with VR simulation using the SSM over dry lab training in improving suturing performance. While users of the SSM did not find all aspects of the simulator realistic in their face validity assessment, they found it useful and relevant as a training tool for improving suturing performance.Date & Time: May 17, 2014 1:00 PM-3:00 PM
Session Title: Technology & Instruments: Surgical Education & Skills Assessment II
Sources of Funding: none

Performance Data Summary
Dry Lab (n=9) VR Simulation (n=10)
Mean (SD) Median [Min, Max] Mean (SD) Median [Min, Max] p-value
Timing Score Initial 235.22 (119.01) 265 [0, 353] 254.3 (144.75) 318.5 [0, 401] 0.5928
Final 407.67 (74.22) 440 [263, 476] 377.5 (51.52) 375.5 [302, 453]
Difference 172.44 (114.38) 154 [18, 360] 123.20 (115.44) 98 [-34, 302] 0.3602
Time (Sec) Initial 355.67 (120.96) 313 [247, 600] 337.7 (146.6) 270 [195, 600]
Final 185.22 (70.1) 159 [123, 327] 212.6 (53.13) 214.5 [143, 291]
Difference -170.44 (117.30) -142 [-350, -15] -125.10 (117.38) -101.50 [-309, 27] 0.4023
Accuracy (mm) Initial 1.38 (1.3) 1 [0, 4] 2.11 (1.27) 2 [0, 4]
Final 0.75 (1.16) 0 [0, 3] 0.78 (1.09) 0 [0, 3]
Difference -0.63 (1.06) -0.50 [-2, 1] -1.33 (1.32) -1 [-3, 1] 0.2726
Gap (mm) Initial 0.13 (0.35) 0 [0, 1] 0.11 (0.33) 0 [0, 1]
Final 0.50 (0.76) 0 [0, 2] 0.56 (1.13) 0 [0, 3]
Difference 0.38 (0.92) 0 [-1, 2] 0.44 (1.24) 0 [-1, 3] 0.8734
Integrity Secure 3 5 3 3
Loose 3 3 6 6
Coming Apart 2 1 0 1
Incomplete 1 0 1 0
Total 9 9 10 10 0.0945
Square Knots Square 0 3 0 2
Not Square 8 6 9 8
Incomplete 1 0 1 0
Total 9 9 10 10 0.6825

 

Saturday, May 17, 2014 1:00 PM-3:00 PM
OCCC: W 307
Technology & Instruments: Surgical Education & Skills Assessment II
Funding: none
MP14-07: Surgical Attention and Movement in Novice and Expert Robotic Surgeons 
Rebecca Zee*, Sierra J Seaman, Matthew Engelhard, Noah S Schenkman, Charlottesville, VA

Abstract: MP14-07
Introduction and Objectives
Surgical simulators are useful tools to develop surgical skills. Surgical skill is partially determined by attention level and movement precision. In this study we utilize two devices: the Body Wave (BW), an EEG device designed to measure attention and the TEMPO, which measures hand movement. We compare attention and hand movements in novice and expert robotic surgeons to identify specific metrics that may be used to enhance surgical skills development.Methods
Subjects were recruited into two groups: expert robotic surgeons who completed at least 50 cases on the daVinci robotic platform (n=12) and novice medical students (n = 28). Subjects performed 3 surgical tasks (Ring Walk= RW, Energy Dissection=ED, and Suture Sponge=SS) on the daVinci simulator while wearing only BW. 27 novices and 6 experts wore both devices during the SS task. Data was collected from the BW and TEMPO using proprietary software. Measurements included % interested, % disinterested, recovery time, completion time, acceleration variance, signal power and overall score. Pre- and post-task surveys and a NASA Task Load Index (NTLI) were performed to assess perceived workload.Results
Experts scored higher than novices in all simulations. On NTLI, experts rated perceived workload lower than novices in 5 categories (mental demand, physical demand, temporal demand, effort, and frustration) and ranked personal performance higher. However, attention was not significantly different. Experts had faster recovery time in the RW (p=0.024), but not ED or SS. For hand movement, experts displayed greater lateral and vertical acceleration variance and greater signal power than novices in the left hand (p<0.01).Conclusions
Our study reveals that experts and novices maintain a similar level of attention on the daVinci simulator. Expert recovery on RW was significantly faster. This is consistent with our findings from a previous BW study. RW recovery appears to be an important differentiator between expert and novice attention patterns. Further, expert surgeons have greater left-handed dexterity compared to novices.Date & Time: May 17, 2014 1:00 PM-3:00 PM
Session Title: Technology & Instruments: Surgical Education & Skills Assessment II
Sources of Funding: none

Attention Measured in Novices and Experts Using Body Wave
Novices (n=28) Experts (n=12) p-value
RW performance score (%) 54.04 89.33 < 0.005
RW attention score (%) 57.18 55.50 0.39
RW recovery time (sec) 13.07 7.92 0.02
ED performance score (%) 62.82 81.08 < 0.005
ED attention score (%) 54.96 55.42 0.47
ED recovery time (sec) 11.37 9.25 0.27
SS performance score (%) 48.50 87.25 < 0.005
SS attention score (%) 61.25 59.42 0.36
SS recovery time (sec) 10.36 8.92 0.28
Left Hand Movement in Novice and Expert Robotic Surgeons
Vertical Acceleration Signal Power (5-10 Hz) Vertical Acceleration Variance Lateral Acceleration Signal Power (5-10 Hz) Lateral Acceleration Variance
Novices 98.18 0.15 42.72 0.07
Experts 201.81 0.39 68.26 0.12
p-value < 0.001 < 0.001 < 0.001 < 0.01

 

Saturday, May 17, 2014 1:00 PM-3:00 PM
OCCC: W 307
Technology & Instruments: Surgical Education & Skills Assessment II
Funding: None.
MP14-08: Laparoscopic and Robotic Curricula Use in Urology Residency Programs: A 5-Year Update 
Kasey Morrison*, Matthew Clements, Noah Schenkman, Charlottesville, VA

Abstract: MP14-08
Introduction and Objectives
Laparoscopic and robotic curricula are designed to provide residents with skills transferable to the operating room. This study aims to evaluate trends in curricula and simulator use in American urology residency programs over the past 5 years.Methods
This is a 5 year update of a study performed in 2008-2009. A survey of participants at the AUA Basic Sciences Course was performed in June 2013 and compared to prior results. This included trainees across all years, with most in the 2nd or 3rd year of residency. All sections of the AUA were represented.Results
70 of 182 surveys were completed for a response rate of 38%. Most respondents were in the 2nd or 3rd year of residency (90%). As expected, most respondents were inexperienced, defined as <= 20 cases as primary surgeon, in both laparoscopic (85%) and robotic experience (93%). Simulator availability has increased overall with 93% of programs having a simulator now up from 78% in 2009. The simulator variability has also changed dramatically as outlined in Table 1. Despite the rise in simulator availability, reported lap/robotic curricula have not increased (44% had curricula in 2009 compared to 37% currently). Furthermore, the presence of a curriculum does not appear to affect the frequency of simulator use (see Table 2).Conclusions
In our sample, representing a large proportion of junior residents nationally, self-reported simulator use has not increased over the past five years. 63% of residents are reporting no formal curricula for lap/robotic training despite increased availability of simulators. These trends are at odds with a movement towards emphasis on simulation throughout residency training.Date & Time: May 17, 2014 1:00 PM-3:00 PM
Session Title: Technology & Instruments: Surgical Education & Skills Assessment II
Sources of Funding: None.

Table 1: Simulator availability
Simulators available 2009 2013
Ureteroscopy 4 (7%) 3 (4%)
Lap Box trainer 52 (90%) 53 (76%)
ProMis simulator 4 (7%) 2 (3%)
Percutaneous renal access simulator 4 (7%) 4 (6%)
VR robotic simulator 8 (14%) 39 (56%)
Nintendo Wii 6 (10%) 2 (3%)
Other 2 (3%) 4 (6%)
Table 2: Comparative simulator use in programs with and without a curriculum
Frequency of use Residents with curriculum Residents without curriculum Total
Never 5 (22%) 11 (26%) 16
1-2 per year 12 (52%) 17 (41%) 29
Once per month 5 (17%) 10 (24%) 15
Every other week 1 (4%) 2 (5%) 3
Once per week 1 (4%) 2 (5%) 3
Total 24 (36%) 42 (63%) 66*

 

Saturday, May 17, 2014 1:00 PM-3:00 PM
OCCC: W 307
Technology & Instruments: Surgical Education & Skills Assessment II
Funding: none
MP14-10: Baseline Urologic Surgical Skills among Medical Students: Differentiating Trainees 
Vishaal Gupta*, Andrea Lantz, Tarek Alzharani, Kirsten Foell, Jason Y Lee, Toronto, Canada

Abstract: MP14-10
Introduction and Objectives
Urology training programs seek to identify ideal candidates with the potential to become competent urologic surgeons. It is unclear whether innate technical ability has a role in this selection process. We aimed to determine whether there are any innate differences in baseline urologic technical skills among medical students.Methods
Second year medical students from the University of Toronto were recruited for this study and stratified into surgical and non-surgical cohorts based on reported career aspirations. After a pre-test questionnaire, subjects were tested on several urologic surgical skills; laparoscopy, cystoscopy, robotic surgery. Statistical analysis was performed using chi-squared test, student t-tests, Spearman’s correlation where appropriate.Results
A total of 29 students participated in the study and no significant baseline differences were found between cohorts with respect to demographics and prior surgical experience. For laparoscopic skills, the surgical cohort outperformed the non-surgical cohort on several exercises; Lap Beans Missed (4.9 vs 9.3, p<0.01), Lap Bean Rating (3.8 vs 3.1, p=0.01), Lap Rings Error (0.2 vs 1.22, p<0.01), Lap Rings Rating (3.9 vs 2.9, p<0.01), and LapSim Grasping Score (64.3 vs 46.4, p=0.01). For cystoscopic skills, there were no significant differences between cohorts on any of the performance metrics. The surgical cohort also outperformed the non-surgical cohort on all measured robotic surgery performance metrics: Task Time (50.6 vs 76.3, p<0.01), Task Errors (0.2 vs 3.1, p<0.01), and Task Score (89.5 vs 72.6, p<0.01).Conclusions
Objective innate technical ability in urological skills, particularly laparoscopy and robotics, may differ between early trainees interested in a surgical career compared to those interested in a non-surgical career. Further studies are required to illicit the impact such differences have on future performance and competence.Date & Time: May 17, 2014 1:00 PM-3:00 PM
Session Title: Technology & Instruments: Surgical Education & Skills Assessment II
Sources of Funding: none

 

Saturday, May 17, 2014 1:00 PM-3:00 PM
OCCC: W 304 A
Urethra: Benign & Malignant Disease
Funding: none
MP13-13: Propensity Matched Comparison of Morbidity and Costs of Open vs. Minimally Invasive Radical Nephroureterectomy: A Contemporary Population-Based Analysis in the United States 
Jeffrey Leow*, Joaquim Bellmunt, Toni Choueiri, Boston, MA, Benjamin Chung, Stanford, CA, Steven Chang, Boston, MA

Abstract: MP13-13
Introduction and Objectives
Nephroureterectomy (NU) is the standard treatment for upper tract urothelial carcinoma. Minimally invasive (laparoscopic or robot-assisted) approaches have gained popularity in recent years. On a population-level, there exists limited data on its utilization, morbidity and costs in the United States.Methods
Using the Premier Comparative Database (Premier, Inc., Charlotte, NC), which collects data from over 600 non-federal hospitals throughout the US, we captured all patients who underwent a NU (ICD-9 code 55.51) with diagnoses of renal pelvis (189.1) or ureteral (189.2) neoplasms, from 2003 to 2010. To reduce selection bias between open and minimally invasive (MI) groups, we employed propensity-weighted statistical analyses, adjusting for clustering by hospitals and survey weighting to ensure nationally representative estimates. We evaluated 90-day mortality, postoperative complications (using Clavien classification), length of stay, and direct hospital costs.Results
The weighted cohort included 26009 open and 18667 MI NUs. The 90-day mortality (Clavien 5), major (Clavien 3-5) and minor complication (Clavien 1-2) rates were 1.8%, 8.0% and 22.5% respectively. Use of MI surgery increased from 27.0% in 2003 to 49.5% in 2010 (p for trend <0.001) (Figure 1). In a propensity-weighted analysis, 90-day mortality rates (2.0% vs. 1.6%, p=0.36; odds ratio [OR]: 0.80, 95% CI: 0.46-1.40, p=0.44) and major complication (8.2% vs. 7.7%, p=0.45; OR: 0.93, 95% CI: 0.70-1.24, p=0.62) rates were similar between open and MI NU. However, MI NU had a 34% decreased odds of prolonged hospital length of stay (>median) (OR: 0.66, 95% CI: 0.55 to 0.79, p<0.001). MI NU had $1186 higher adjusted 90-day median direct hospitals (p<0.001).Conclusions
Between 2003 and 2010, the use of MI NU has increased significantly now accounting for approximately half of all procedures. There was no postoperative mortality and morbidity advantage of MI over open NU. Although hospital length of stay was shorter, MI NU still had higher direct hospital costs. Long-term oncological and functional outcomes of MI NU remain to be seen.Date & Time: May 17, 2014 1:00 PM-3:00 PM
Session Title: Urethra: Benign & Malignant Disease
Sources of Funding: none

 

Saturday, May 17, 2014 10:30 AM-12:30 PM
OCCC: W 314
General & Epidemiological Trends & Socioeconomics: Practice Patterns, Cost Effectiveness II
Funding: This study was funded by grants from the Agency for Healthcare Research and Quality (R01 HS018535) and The University of Chicago Cancer Research Foundation Women’s Board.
MP11-04: Adoption of Robot-Assisted Surgery and Its Impact on Treatment Patterns for Newly Diagnosed Localized Prostate Cancer 
Scott Eggener*, Chicago, IL, Jim Hu, Los Angeles, CA, Chan Shen, Houston, TX, Tina Shih, Chicago, IL

Abstract: MP11-04
Introduction and Objectives
With the rapid increase of robotic surgical systems in hospitals, it is important to understand the impact on treatment patterns for localized prostate cancer. The objective of this study is to determine whether the presence of robotic surgical systems independently influenced rates of surgery, radiation, and active surveillance for localized prostate cancer.Methods
We conducted an observational study using National Cancer Database (NCDB) state-level data, 2002-2010. Our study cohort includes patients newly diagnosed with clinical stage I-III prostate cancer from 48 states and Washington D.C. in the United States. The number of robotic systems installed in each state over time was obtained from publicly available information on-line. We characterized the state-level treatment pattern as the proportion of patients having surgery, radiation and active surveillance as their first course of treatment.Results
Between 2002 and 2010, the average number of robotic surgical systems per state increased from 2 to 26.3, while the unadjusted rate of surgery increased from 37.5% to 52.4%, radiation therapy decreased from 43.3% to 30.2%, and active surveillance increased from 7.0% to 9.3%. For every 10 additional robotic systems installed in a state, there would be a 2.5% increased rate of surgery (p<0.01), accompanied by a 1.3% (p=0.04) and 1.0% (p<0.01) decrease in the rate of radiation and active surveillance, respectively. For every additional urologist per 100,000 people, rates of surgery increased 2.5% (p=0.03). Subgroup analyses suggest that the robotic adoption crowding out effect on radiation and active surveillance was driven primarily by men with stage I-II prostate cancer. If the adoption trajectory for robotic systems continues, the increased cost of treating localized prostate cancer in 2012 will exceed $26 million.Conclusions
During a period of rapid acquisition of robotic surgical systems, we found the number of robotic systems available at the state-level is significantly and directly associated with a higher rate of surgery for localized prostate cancer and lower rates of radiation therapy and active surveillance.Date & Time: May 17, 2014 10:30 AM-12:30 PM
Session Title: General & Epidemiological Trends & Socioeconomics: Practice Patterns, Cost Effectiveness II
Sources of Funding: This study was funded by grants from the Agency for Healthcare Research and Quality (R01 HS018535) and The University of Chicago Cancer Research Foundation Women’s Board.Open Attachment

 

Saturday, May 17, 2014 10:30 AM-12:30 PM
OCCC: W 314
General & Epidemiological Trends & Socioeconomics: Practice Patterns, Cost Effectiveness II
Funding: None
MP11-17: Urologic Malpractice: Increasing Frequency and Cost of Prostate Cancer Related Claims 
Benjamin A Sherer*, Kalyan C Latchamsetty, Christopher L Coogan, Chicago, IL

Abstract: MP11-17
Introduction and Objectives
The risk of medical malpractice litigation creates real concern for practicing Urologists. We seek to identify the errors and procedure types most commonly resulting in closed claims in the past decade. We also quantify associated costs of litigation based on error implicated.Methods
An analysis of claims was performed on data from 22 member companies of the Physician Insurers Association of America (PIAA) from 1985-2012. Data included 6,751 closed claims in Urologic surgery.Results
The most prevalent error in Urologic surgery in the past decade was “improper performance of a procedure”, accounting for 880 (34%) closed claims. Of these, procedures involving the prostate were most frequently implicated (110 claims) and 36% resulted in an indemnity payment (average indemnity payment: $451,421). Other common errors included “error in diagnosis” (329 closed claims) and “failure to recognize a complication” (141 closed claims). Errors in the management of kidney stones accounted for the most closed claims in the past decade (245). In the past three years, prostate cancer (26 closed claims in 2012) has become the most likely presenting patient condition to result in closed claims. Errors in the management of prostate cancer now account for the highest average indemnity payments ($459,545 in 2012).Conclusions
Costs of urologic litigation continue to rise at an alarming rate. Improper performance of a procedure is the most likely Urologic error to result in litigation. Traditionally, error in the management of nephrolithiasis resulted in the most closed claims. However, in the past five years, error in the management of prostate cancer has resulted in the most claims and highest average indemnity payment. This may correlate with the increasing use of robotic assisted surgery in the management of prostate cancer. Understanding the most common errors and procedure types leading to malpractice claims can help Urologists with risk management and potentially lead to improved patient care.Date & Time: May 17, 2014 10:30 AM-12:30 PM
Session Title: General & Epidemiological Trends & Socioeconomics: Practice Patterns, Cost Effectiveness II
Sources of Funding: None
Saturday, May 17, 2014 10:30 AM-12:30 PM
OCCC: W 307
Trauma/Reconstruction: Trauma & Reconstructive Surgery III
Funding: None
MP9-13: New Insight Into Post-Robotic Prostatectomy Bladder Neck Contracture: The Role Of Extruded Hemolock Clips 
ALAA HAMADA*, Sanjay Razdan, Miami, FL

Abstract: MP9-13
Introduction and Objectives
Post radical prostatectomy bladder neck contracture (BNC) is moderate to severe scarring process involving urethrovesical (U-V) anastomosis resulting in bladder outlet obstruction. Its incidence has been notably reduced with use of robotic assisted laparoscopic prostatectomy (RALP).Weck clips have been used to ligate lateral vascular pedicles and aid in dissection of neurovascular bundles. Objective: To examine BNC developed after RALP in terms of prevalence, clinical presentation pattern, cystoscopic findings, possible associated risk factors and response to treatment.Methods
After obtaining IRB approval, the retrospective data of 1718 men with prostate cancer who underwent RALP by a high volume surgeon in the period between May, 2004 and June, 2012 were prospectively analyzed to investigate prevalence and risk factors of BNC. The recorded data included clinical, laboratory perioperative, cystoscopic findings (presence of stricture, extruded Weck Hemolock clips and associated bladder stone), number of contemplated laser bladder neck incision (BNI) procedures and rate of recurrence. In all patients, urethrovesical (U-V) anastomosis was performed using Van-Velthoven technique, utilizing running double-armed 3-0 Monocryl suture.Results
Prevalence of post-RALP BNC after a median follow-up period of 24 months, was 43/1718 (2.5%).BNC developed after a mean and median period of 9.9 and 6 months, respectively. Within patients with BNC, two categories were identified based on cystoscopic findings: a) 23 patients (53%) had pure U-V anastomotic stricture related BNC (SRBNC) and b) 20 patients (46.5%) had stricture-Weck clip related BNC (SCRBNC), in which single or multiple Hemolock Weck clips were extruded into the U-V anastomotic region resulting into anastomotic stricture. By comparing both groups, no differences were seen in the analyzed parameters. After undergoing laser BNI and removal of extruded clips, recurrence rates of BNC was higher in the SCRBNC (60%) than in SRBNC group (26%) (p=0.025). Patients with SCRBNC required at least 2.2 procedure per patient vs. 1.3 laser BNI procedure in the SRBNC group (P=0.015).Conclusions
Extruded Hemolock Weck clips into vesico-urethral anastomosis in patients who underwent RALP, constitute significant predisposing factor for nearly half of cases of bladder neck contracture and is responsible for its recurrence. Use of biodegradable clips are encouraged to minimize BNC.Date & Time: May 17, 2014 10:30 AM-12:30 PM
Session Title: Trauma/Reconstruction: Trauma & Reconstructive Surgery III
Sources of Funding: None

Table 1. Shows the preoperative, operative and postoperative parameters of the two categories of BNC.
Parameter Pure Stricture Clip Related Stricture P value
Patients 23 (53.5%) 20 (46.5%)
Age / years 63.3 61.4 0.46
PSA ng/ml 7.5 8.1 0.7
Gleason score G 3+3=6: 15 (65.2%) 10 (50%)
G 3+4=7 or 4+3=7: 8(34.8%) 7 (35%) 0.3
G 4+4=8:0 (0%) 2(10%)
G ≥ 4+5=9: 0(0%) 1(5%)
Prostate volume /g 42.4 47.9 0.3
Operative time/minute 79.8 77.5 0.2
Prolonged urine leak (>150cc/24hour) 3 1 0.6
EBL/ml 102 115 0.8
Time of presentation/months 8 11.4 0.25
Clinical presentation Retention 5 (21.7%) 2 (10%)
LUTS 17 (73.9%) 15(75%)
Infection 0 (0) 1(5%) 0.5
Hematuria 0 (0) 1(5%)
Recto-urethral Fistual 1(4.3%) 1(5%)
Rate of continence after BNI 22/23 (95.6%) 19/20 (95%) 0.9
Associated stone 5 (21.7%) 3 (15%) 0.6
Average and range of number of therapeutic BNI 1.3 (1-3) 2.2 (1-6) 0.015
Proportion of men with recurrence after BNI 6 (26%) 12 (60%) 0.025
Average Follow up/ months 30.4 27.5 0.7
Post-op BCR 0 (0) 2 (10) 0.2
Loco-regional disease 2(8.7%) 4(20%) 0.4

 

Source: AUA 2014 

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