ROBOTICS AND UROLOGY. 3/5 ABSTRACTS MEETING OF THE AMERICAN UROLOGICAL ASSOCIATION.

Saturday, May 17, 2014 10:30 AM-12:30 PM
OCCC: W 303
Technology & Instruments: Surgical Education & Skills Assessment I
Funding: None
PD6-01: The Learning Curve for Laparoscopic Robot Assisted Partial Nephrectomy Matched by Tumor Complexity for an Experienced Laparoscopic Surgeon 
Hitesh Dube*, Clinton Bahler, Chandru Sundaram, Indianapolis, IN

Abstract: PD6-01
Introduction and Objectives
Due to the technical challenges of laparoscopic partial nephrectomy (LPN), surgeons are increasingly utilizing robotic assistance for minimally invasive partial nephrectomies. Since the first laparoscopic robot assisted partial nephrectomy (LRPN) at IU Health in 2007, a single surgeon experienced in LPN (CS) has performed 146 LRPNs. We assessed the learning curve to adjust to LRPN and used nephrometry scores for matching. We defined the learning curve as the number of cases needed to achieve a mean warm ischemia time of twenty minutes or less.Methods
Between 2007 and 2013, 146 patients with small renal masses underwent RPN. In a retrospective analysis, demographic, perioperative, and oncologic variables were examined using SPSS. The data was analyzed with and without matching for tumor complexity based on nephrometry scoring. The learning curve, defined as the time needed for the majority of surgeries after a given date to have a warm ischemia time (WIT) of twenty minutes or less, was extrapolated from a scatter plot of WIT as a function of operation date.Results
Comparing the first 30 to the 30 most recent cases, we found a significant increase in tumor size (2.53 to 3.20 cm, p < 0.01) and tumor complexity (nephrometry score: 5.97 to 7.77, p < 0.01), as well as a significant decrease in mean warm ischemia time (WIT: 25.33 to 20.03 minutes, p < 0.01), in the more recent procedures. We found our learning curve to achieve a warm ischemia time of less than twenty minutes was 64 cases. After partitioning the patients into two groups—pre- and post- learning curve—we matched patients between groups based on nephrometry score. In the latter group, a significant decrease in warm ischemia time (24.283 to 18.53 minutes, p < 0.01) was observed. Tumor diameter (2.826 and 2.8 cm, p > 0.8), nephrometry scores (6.40 and 6.47, p > 0.8), and length of stay (2.63 and 2.62 days, p > 0.8) were the same, while the remaining outcomes were not significantly different (estimated blood loss: 180.5 and 284.4 mL, p > 0.4; procedure time: 214.6 and 222.5 minutes, p > 0.8; complication rate: 17.7% and 17.1%, p > 0.1).

Conclusions
A learning curve of 64 cases for robotic partial nephrectomy was seen in an experienced laparoscopic surgeon. A significant decrease in warm ischemia time was observed, despite a corresponding increase in the complexity of tumors removed.

Date & Time: May 17, 2014 10:30 AM-12:30 PM
Session Title: Technology & Instruments: Surgical Education & Skills Assessment I
Sources of Funding: None

 

Saturday, May 17, 2014 10:30 AM-12:30 PM
OCCC: W 303
Technology & Instruments: Surgical Education & Skills Assessment I
Funding: none
PD6-03: Multi-institutional Validation of Fundamental Inanimate Robotic Skills Tasks (FIRST) 
Monty Aghazadeh*, Miguel Mercado, Houston, TX, Andrew Hung, Mihir Desai, Inderbir Gill, Los Angeles, CA, Brian Dunkin, Alvin Goh, Houston, TX

Abstract: PD6-03
Introduction and Objectives
Our group has previously reported on the development and validation of FIRST, a series of 4 inanimate robotic skills training tasks. Expanding on initial validation, we now demonstrate face, content, and construct validity of these tasks in a large multi-institutional cohort of experts and trainees.Methods
Ninety-six residents and attending surgeons were enrolled at participating institutions between 2011-2013. After watching an instructional video, participants completed each task in succession. Performance metrics were based on accuracy and efficiency. Face and content validity were derived from participants’ and experts’ rating of the tasks on a 5-point Likert scale, evaluating 1) difficulty, 2) similarity to skills required for robotic surgery, 3) usefulness for skills evaluation, 4) usefulness in skills training, and 5) requirement for proficiency. For statistical analysis, participants were grouped based on robotic experience into novice (<5 robotic cases as primary surgeon), intermediate (≥5 but ≤30), and expert (>30) groups.Results
Forty-nine novice, 22 intermediate, and 23 expert surgeons were assessed across all four inanimate robotics skills tasks. Median number of robotic cases (range) performed by the novice, intermediate, and expert groups were 0 (0-3), 10 (5-30), and 200 (55-2000), respectively [p<0.001]. Not only did the expert and intermediate groups reliably outperform novices, but experts also outperformed intermediates in all exercises (see Figure 1). Face Validity: Of all participants, 75% agreed that the tasks were an appropriate level of difficulty and 84% agreed that the necessary technical skills reflect robotic surgery skills. Content Validity: Of expert participants, 95% agreed that the tasks were useful for skills evaluation; 100% agreed that the tasks were useful for training and that a skilled robotic surgeon should be able to perform all the tasks presented.

Conclusions
In this study we confirm the face, content, and construct validity of four inanimate robotic training tasks in a multi-institutional cohort. We demonstrate that FIRST are reliably able to discern between expert, intermediate, and novice surgeons. Validation data from this large multi-institutional cohort is useful as we incorporate FIRST into a comprehensive robotic training curriculum.

Date & Time: May 17, 2014 10:30 AM-12:30 PM
Session Title: Technology & Instruments: Surgical Education & Skills Assessment I
Sources of Funding: none

 

Saturday, May 17, 2014 10:30 AM-12:30 PM
OCCC: W 303
Technology & Instruments: Surgical Education & Skills Assessment I
Funding: None
PD6-07: Augmented reality video simulation for robotic partial nephrectomy surgery training – the next generation 
Andrew J. Hung*, Daniel H. Shin, Wesley Yip, Inderbir S. Gill, Los Angeles, CA

Abstract: PD6-07
Introduction and Objectives
Mimic Technologies and USC Urology have jointly developed a prototype simulation interface featuring augmented video on the dV-Trainer. Users observe 3D video of robotic kidney surgeries and use virtual instruments to identify anatomy, demonstrate technical skills, and learn operation steps. Herein, we evaluate the face, content, and construct validity of the next generation simulation, which features expanded modules with special focus on anatomy.Methods
Participants were classified as “novice” (no prior robotic cases, n=28) or “expert” (≥30 cases, n=10) and prospectively assessed on 3 modules of a robotic partial nephrectomy: colon mobilization duodenal Kocherization and hilar dissection. Questions were categorized as anatomy, technical, or steps, and metrics were analyzed with 2-sided t tests (construct validity). A post-study questionnaire assessed realism of simulation (face validity) and utility for training (content validity).Results
Novices and experts had performed a median of 0 and 150 (range 35-1000) robotic cases (p<0.001). Experts rated the modules as realistic (average 7/10) and helpful (8/10) in resident training. Overall, experts completed the exercises more accurately (p<0.001) and efficiently (p=0.02) than novices. Detailed analysis revealed that in Module 1, novices initially identified anatomy slower than experts (p=0.002), but with question repetition, their performance in the latter third of the module equaled the experts (p=0.16).

Conclusions
This next-generation augmented reality prototype simulation displays face and content validity, with expanded construct validity in teaching anatomy, retraction skills and steps of surgery. It is the first of its kind to statistically demonstrate the ability to teach surgical anatomy to novices so that their recognition ability nears that of experts. Contemporary surgical simulation requires vigorous step-wise validation throughout the development process.

Date & Time: May 17, 2014 10:30 AM-12:30 PM
Session Title: Technology & Instruments: Surgical Education & Skills Assessment I
Sources of Funding: None

 

Saturday, May 17, 2014 10:30 AM-12:30 PM
OCCC: W 303
Technology & Instruments: Surgical Education & Skills Assessment I
Funding: Department of Defense Grant W81XWH-09-1-0714 “Virtual Reality Robotic Simulation for Robotic Task Proficiency: A Randomized Prospective Trial of Pre-Operative Warm-up”. Department of Urology, University of Washington, Seattle, WA
PD6-08: Crowd-Sourced Assessment of Technical Skills (C-SATS™): Fast, Economical and Accurate Assessment of Robotic Surgery 
Lee W. White*, Stanford, CA, Timothy Kowalewski, Minneapolis, MN, Timothy Brand, Tacoma, WA, Jonathan Harper, Bryan Comstock, Blake Hannaford, Thomas S. Lendvay, Seattle, WA

Abstract: PD6-08
Introduction and Objectives
Surgeon skill has recently been shown to predict patient outcome when measured using objective structured assessment tools. However, the time-cost to have expert surgeons grade surgical videos is great. We hypothesized that crowd-sourcing of surgical skills assessment would be as accurate as and faster than conventional expert surgeon graders rating the same surgical performances.Methods
Fifty-one urology residents and faculty performed two dry-lab surgical training tasks on a da Vinci surgical robot: 1) Fundamentals of Laparoscopic Surgery intracorporeal suturing and 2) a rocking pegboard transfer task. Forty-nine recorded performances from each were available to be uploaded to a website built to facilitate efficient grading using the depth perception, bimanual dexterity and efficiency domains of the validated Global Evaluative Assessment of Robotic Surgery scoring tool. Three surgical faculty graded the tasks after completing a grader training session to maximize agreement. Each performance was then scored by 30 Amazon.com Mechanical Turk crowd workers in return for a payment of $0.25 to $0.50. Mean surgeon and mean crowd scores were computed and compared using correlation coefficient (CC) and Cronbach’s Alpha (CA), a measure of crowd-surgeon agreement.Results
Figure 1. shows the agreement between surgeon scores and C-SATS™ scores. The CC between surgeon grade and C-SATS™ was 0.79 for rocking pegboard and 0.86 for suturing. CA was 0.84 for the rocking pegboard and 0.92 for suturing, indicating ‘good’ and ‘excellent’ agreement, respectively. 67% of the C-SATS™ scores for rocking pegboard and 69% of the C-SATS™ scores for suturing fell within 1 point of the surgeon-provided score on a 3-15 point possible score range. The cost to assess these surgical performances was small: $10.07 per rocking pegboard video and $15.67 per suturing video. Furthermore, crowds provided scores in 9 hours for 49 suturing videos compared to over a month for the surgeon panel.

Conclusions
This is the first demonstration of untrained crowds accurately assessing robotic surgical performances on diverse tasks, representing a wide range of surgeon skill levels. Also, C-SATS™ can be much faster than relying on faculty assessments. Future studies are needed to compare crowd assessment of surgeries on real patients to complications and clinical outcomes. If correlated, this type of assessment could be central to the surgical resident training and credentialing processes.

Date & Time: May 17, 2014 10:30 AM-12:30 PM
Session Title: Technology & Instruments: Surgical Education & Skills Assessment I
Sources of Funding: Department of Defense Grant W81XWH-09-1-0714 “Virtual Reality Robotic Simulation for Robotic Task Proficiency: A Randomized Prospective Trial of Pre-Operative Warm-up”. Department of Urology, University of Washington, Seattle, WA

 

Saturday, May 17, 2014 10:30 AM-12:30 PM
OCCC: W 303
Technology & Instruments: Surgical Education & Skills Assessment I
Funding: none
PD6-09: Effect of Post-Call Fatigue Measured by Robotic Skills Simulator 
Aaron Weinberg*, Solomon Woldu, Tammer Yamany, Ruslan Korets, Ketan Badani, New York, NY

Abstract: PD6-09
Introduction and Objectives
Studies on post-call residents have shown that manual dexterity and surgical skills are worsened by fatigue following a 24-hour call. National work-hour restrictions have been initiated for certain levels of residency training to prevent complications and maximize patient care. The purpose of this study was to examine the effect of a 24-hour call on resident performance of a suturing task using the objective results calculated by the da Vinci Skills Simulator (Intuitive Surgical, Sunnyvale, CA).Methods
Residents from urology and general surgery completed a single suturing skill immediately before and after a 24-hour call. Residents completed the task at least twice; and were scored on 3 measures: time to complete exercise, time to load needle, and time to tie knot. These scores were correlated with previous simulator experience, trainee level, and level of post-call fatigue.Results
13 residents (4 senior and 9 junior) participated, 7 had no simulator experience. All time measures were significantly longer when residents were fatigued (p<0.05). Both in the pre- and post-call measures, previous robotic simulator experience was associated with improved times for completion of the exercise, needle loading, and knot tying (Table 1). When examining factors that predicted an increased task time on multivariate analysis, fatigue consistently increased time to complete the exercises, while previous simulator experience and trainee level decreased the time to complete tasks (Table 2).

Conclusions
Previous studies have shown that fatigue is associated with decreased surgical skills and patient outcomes in the operative room. We replicated this effect using the robotic simulator that allows for objective measurements. Time to complete the 3 measures analyzed was significantly increased following a 24-hour call; this difference remained statically significant even after factoring resident experience with the surgical simulator. A standardized training program can help improve robotic skills, especially for junior residents with minimal experience, but fatigue appears to remain a factor in performance on these objective parameters.

Date & Time: May 17, 2014 10:30 AM-12:30 PM
Session Title: Technology & Instruments: Surgical Education & Skills Assessment I
Sources of Funding: none

 

Saturday, May 17, 2014 10:30 AM-12:30 PM
OCCC: W 303
Technology & Instruments: Surgical Education & Skills Assessment I
Funding: None
PD6-10: Does fellow and chief-resident training affect perioperative outcomes of robot-assisted radical prostatectomy? 
Ziho Lee*, Andrew Lightfoot, Shailen Sehgal, Reid Graves, Phillip Mucksavage, David Lee, Philadelphia, PA

Abstract: PD6-10
Introduction and Objectives
To determine whether fellow and chief-resident participation during robot-assisted radical prostatectomy (RARP) influences perioperative outcomes.Methods
Between August 2011 and June 2012, 388 patients underwent RARP by a single primary surgeon (DIL) at our institution. Our teaching algorithm divides RARP into six stages. Each trainee may progress to the next stage in a sequential manner once the trainee demonstrates competency as determined by the primary surgeon. Patient characteristics and perioperative outcomes were compared after dividing our cohort according to the surgeon(s) operating the robotic console: attending only (n=91), attending and fellow (n=152), and attending and chief-resident (n=145). Approximately normal variables were compared utilizing one-way analysis of variance test, and categorical variables were compared utilizing two-tailed chi-square (χ2) test; p<0.05 was considered statistically significant.Results
Among the three groups, there was no difference in patient characteristics such as mean age (p=0.590), body mass index (p=0.339), preoperative Sexual Health Inventory for Men (SHIM) score (p=0.084), preoperative American Urology Association Symptom Score (p=0.086), preoperative prostate-specific antigen (p=0.258), preoperative Gleason score (p=0.176), postoperative Gleason score (p= 0.779), clinical stage (p=0.766), and pathological stage (p=0.699). There was no difference in perioperative outcomes such as mean estimated blood loss (p=0.807), length of stay (p=0.494), and rate of positive surgical margins (p=0.058). Procedures involving trainees had longer mean operative times (p<.001; attending only=89.3 min, attending and fellow=125.4 min, and attending and chief-resident=126.9 min). At 3 months and 1 year postoperatively, there was no difference in urinary continence rate (p=0.977 and p=0.720, respectively) and SHIM score (p=0.661 and p=0.890, respectively).

Conclusions
Fellow and chief-resident involvement during RARP may be associated with increased operative times, but does not compromise oncologic and functional outcomes at 3 months and 1 year postoperatively.

Date & Time: May 17, 2014 10:30 AM-12:30 PM
Session Title: Technology & Instruments: Surgical Education & Skills Assessment I
Sources of Funding: None

 

Saturday, May 17, 2014 10:30 AM-12:30 PM
OCCC: W 303
Technology & Instruments: Surgical Education & Skills Assessment I
Funding: None
PD6-12: Single versus Dual Console Robot Assisted Laparoscopic Prostatectomy: Impact on Intraoperative and Postoperative Outcomes 
Maurilio Garcia-Gil, Dallas, TX, Nabeel Shakir*, Bethesda, MD, Monica Morgan, Asim Ozayar, Jeffrey Gahan, Claus Roehrborn, Jeffrey Cadeddu, Dallas, TX

Abstract: PD6-12
Introduction and Objectives
Robot-assisted laparoscopic prostatectomy (RALP) has increasingly become the standard surgical treatment of prostate cancer (PCa). However, training urologists to perform RALP is challenging as the single console system often requires the observer to view the case in 2 dimensions, hindering assessment of technique. Further, having to switch seats to resume control of the console impedes transfer between surgeons and may result in poorer outcomes. With the introduction of a dual console system, many of these issues have been addressed. We compared the outcomes of a dual versus single console system using intraoperative, perioperative, and postoperative measures.Methods
Patients with biopsy-confirmed PCa who underwent RALP prior to and after implementing a dual-console system were retrospectively reviewed from 2006-2012. All surgeries were performed by a single faculty surgeon at our institution well after the learning curve had been established (>250 cases), with resident participation. Demographic, intraoperative and pathologic parameters for each patient were obtained. Minimum follow-up was 1.5 years. Continence and erectile function were assessed at 6 and 12 months, in pads per day and the International Index of Erectile Function (IIEF) metric respectively. Postoperative complications were graded using the Clavien-Dindo classification. Uni- and multivariate analyses were conducted using the JMP package.Results
Of 381 patients identified, 185 and 196 underwent single- or dual-console RALP respectively. There was a significant decrease in operative time using the dual console system (171±44 vs. 222±43 minutes, p<0.0001) as well as in the incidence of intraoperative complications (1.53% vs. 8.65%, p=0.002) and postoperative complications (6.63% vs. 14.1%, p=0.02.) Complications of greater Clavien grade occurred more frequently with a single console system (≥3b: 7.01% vs. 1.02%, p=0.003.) These differences persisted when controlling for age, prostate-specific antigen (PSA) level, Gleason score, and pathologic stage by multivariate logistic regression. No statistical difference was found between the cohorts in other postoperative outcomes including incidence of biochemical recurrence, continence, or IIEF.

Conclusions
When training resident surgeons to perform RALP, a dual console system may improve intraoperative and perioperative outcomes and may represent a safer and more efficient modality as compared to a single console system.

Date & Time: May 17, 2014 10:30 AM-12:30 PM
Session Title: Technology & Instruments: Surgical Education & Skills Assessment I
Sources of Funding: None

 

Saturday, May 17, 2014 3:30 PM-5:30 PM
OCCC: W 304 A
Stone Disease: Therapy II
Funding: Turkish Science and Technological Research Office and Elmed Lithotripsy System
MP18-09: Robotic flexible ureterorenoscopy, for the treatment of kidney stones 
Jens Rassweiler*, Heilbronn, Germany, Ahmet Yaser Muslumanoglu, Istanbul, Turkey, Zafer Tokatli, Ankara, Turkey, Turhan Caskurlu, Kemal Sarica, Istanbul, Turkey, Yasar Ozgok, Ankara, Turkey, Abdullah Armagan, Istanbul, Turkey, Mut Safak, Ankara, Turkey, Ali Ihsan Tasci, Bulent Erkurt, Istanbul, Turkey, Gurdal Inal, Remzi Saglam, Ankara, Turkey

Abstract: MP18-09
Introduction and Objectives
Flexible ureterorenoscopy (fURS) has rapidly gained popularity in the treatment of renal stones during the last decade. With increasing indications and utilization efforts concentrate on increased maneuverability and durability of scopes while decreasing surgeons’ fatigue and radiation exposure. After the safety tests in pigs and maneuverability tests on the kidney model of Minnesota University, we planned to search safety and effectivity of the new «Remote robotic control system for flexible Ureterorenoscopy» called «Roboflex Avicenna» (ELMED, Turkey).Methods
After having the informed consents, we treated 42 stones robotically and 18 stones manually as a control group. All patients were suitable for fURS stone treatment from ten institutions were enrolled in to the study. Routine preoperative tests and imaging were performed to all patients. Additionally volume of each stone, calculated by a special software of CT. After insertion of a ureteral access sheath, videoscope (FlexXC Storz, Germany) was introduced into the sheath manually. Then the scope was connected to the Roboflex, and the time for this procedure had been recorded. Console and chair of Roboflex, adjusted ergonomically. Deflection can be performed by manipulating the right handle similar to standart fURS. Precise deflection provided from the whell on the console. The rotation and forward and backward movement can be controlled by left handle. Ureterorenoscopic exploration of all calyceal systems were performed and stones were fragmented using the users own laser devices. Fragments smaller than 1-2 mm were left for spontaneous passage. The fragmentation time recorded and the fragmented volume per minute was calculated. At the end of the procedures, ureteral j stents were placed whenever indicated.Results
Patients age was between 68 – 6 years old. Mean Stone Volume was 1568 cubicmm (432-4085 cubicmm). Mean connection time to the Roboflex was 57 seconds, but in an experienced center after 14 cases it decreased to 44 seconds. Mean fragmented volume per minute was 36 cubicmm/min for manual fURS and 29 cubicmm/min for robotic fURS, but it increased to 33 cubicmm/min for the user with a 14 cases of experience. Stone-free status including fragments up to 2mm as controlled with plain x-ray on day 1 was achieved in all cases. Fever not exceeding one day was seen in 2 patients. There were no damage of the kidney or urinary system.

Conclusions
Robot assisted flexible ureterorenoscopy using Roboflex has been detected as a safe and effective treatment method. It offers performing the fURS procedure out of radiation exposure area while sitting.

Date & Time: May 17, 2014 3:30 PM-5:30 PM
Session Title: Stone Disease: Therapy II
Sources of Funding: Turkish Science and Technological Research Office and Elmed Lithotripsy System

 

Saturday, May 17, 2014 8:00 AM-10:00 AM
OCCC: W 307
General & Epidemiological Trends & Socioeconomics: Practice Patterns, Cost Effectiveness I
Funding: none
MP6-01: Flow Disruptions in Robotic Prostatectomy 
Christopher Dru*, Ken Catchpole, Samantha Jagannathan, Bruno Gross, Niv Hakami-Majd, Jennifer Anger, Los Angeles, CA

Abstract: MP6-01
Introduction and Objectives
Flow disruptions are intra-operative deviations from the optimal course of care that can reduce efficiency, lead to more serious problems, and indicate where the systems of care are failing to deliver the best performance. Previous research demonstrates that they can occur every 5-10 minutes (Wiegmann 2008). We applied the principles of human factors research to robotic prostatectomy in order to better understand where care is inefficient or suboptimal.Methods
After IRB approval, 19 robotic prostatectomy cases were observed. Flow disruptions during robotic prostatectomy were compared by operative step and sorted into nine categories, as previously described by Parker et al (2010). These included disruptions in communication (COM), coordination (COO), instrument changes (IC), surgeon decision-making time (SDM), external/extraneous (EXT), training of residents (TRN), equipment issues (EQ), environment (ENV), and patient factors (PF).Results
On average, 27 flow disruptions occurred per prostatectomy. In contrast, this compares to 48 flow disruptions per case in other urologic/gynecologic robotic procedures observed. The most common flow disruptions in robotic prostatectomy were coordination disruptions, including missing or mishandled equipment. The second most common flow disruptions were equipment disruptions, including primary malfunction and surgeon unfamiliarity with robotic equipment. Average operating room time for robotic prostatectomy was 266+-43 minutes, and flow disruptions during robotic prostatectomy averaged 116+-19 minutes per case. Overall, approximately 44% of operating room time was due to flow disruptions.

Conclusions
Flow disruptions occur frequently and predictably in robotic prostatectomy. Despite the fact that robotic prostatectomy had fewer flow disruptions than other robotic urologic/gynecologic procedures, 44% of operating room time was still consumed by flow disruptions. These findings present an opportunity to enhance safety, quality, efficiency, and learning associated with surgical robotics through the reduction of flow disruptions.

Date & Time: May 17, 2014 8:00 AM-10:00 AM
Session Title: General & Epidemiological Trends & Socioeconomics: Practice Patterns, Cost Effectiveness I
Sources of Funding: none

 

Saturday, May 17, 2014 8:00 AM-10:00 AM
OCCC: W 307
General & Epidemiological Trends & Socioeconomics: Practice Patterns, Cost Effectiveness I
Funding: none
MP6-07: Does robotic-assistance confer an economic or clinical benefit over laparoscopy in radical nephrectomies? 
David Y Yang*, M Francesca Monn, Clint D Bahler, Chandru P Sundaram, Indianapolis, IN

Abstract: MP6-07
Introduction and Objectives
While robotic-assisted (RA) radical nephrectomy has been demonstrated to be safe with comparable outcomes and complication rates to the laparoscopic approach, there is little evidence that RA provides an economic benefit.Methods
From the 2009-2011 Nationwide Inpatient Sample (NIS) database, ICD-9 codes were used to identify all adult patients undergoing radical nephrectomy (55.51) for primary renal malignancy (189.0, 189.1). RA and laparoscopic techniques were identified. Patients operated on with open technique and those with evidence of metastatic disease were excluded from the study. Patients were weighted, using NIS discharge weights, to provide national estimates. Descriptive statistics were performed using Chi-squared test, Student’s T-test and Mann-Whitney tests. Multiple linear regression was performed examining factors associated with changes in total charges.Results
30,634 radical nephrectomy cases were identified for inclusion and, of these, 8,783 (29%) were performed robotically. Patients undergoing RA nephrectomy were younger and more commonly male (p<0.001 each). Median total charges to patients was $47,516 for RA and $38,140 for laparoscopic (p<0.001) (Table 1). Median reimbursement cost to the hospital for RA nephrectomy was $15,624 vs. $11,599 for laparoscopic (p<0.001). There were no differences in Charlson comorbidity index (CCI) score, peri-operative complications, or rate of death (Table 1). RA compared with laparoscopic conferred an estimated $11,267 increase in charges when adjusted for CCI, peri-operative complications, and length of stay (p<0.001) (Table 2).

Conclusions
RA results in an increased medical cost without demonstrating improvement in morbidity or mortality rates. Therefore, robotic technology should be reserved primarily for complex surgeries requiring reconstruction while traditional laparoscopic techniques should continue to be used for routine radical nephrectomies.

Date & Time: May 17, 2014 8:00 AM-10:00 AM
Session Title: General & Epidemiological Trends & Socioeconomics: Practice Patterns, Cost Effectiveness I
Sources of Funding: none

Characteristics of laparoscopic and robotic-assisted radical nephrectomy
Factor Laparoscopic, n(%) RA, n(%) p-value
Charlson Comorbidity Index 0.478
-0 16611 (76) 6555 (75)
-1 2163 (10) 1007 (11)
-2 2428 (11) 951 (11)
-≥3 650 (3) 270 (3)
Length of stay*, mean (SD) 4.2 (4.6) 4.0 (4.7) 0.152
Complication 2536 (12) 977 (11) 0.591
In hospital mortality 115 (0.5) 50 (0.6) 0.863
Total charges, median (IQR) $38,140 ($27,335-$56,241) $47,516 ($35,019-$70,854) < 0.001
Total cost, median (IQR) $11,599 ($8,920-$15,581) $15,624 ($11,889-$21,265) < 0.001
Factors associated with total charges for radical nephrectomy
Factor Coefficient 95% Confidence Interval p-value
Robotic $11,267 $9,447-$13,088 < 0.001
CCI $2,813 $1,465-$4,161 < 0.001
Complication $5,682 $1,586-$9,778 0.007
Length of stay $6,609 $5,938-$7,279 < 0.001
Base charge $21,441 $19,388-$23,495 < 0.001

 

Saturday, May 17, 2014 8:00 AM-10:00 AM
OCCC: W 308
Imaging/Radiology II
Funding: none
MP7-04: 3-D Volumetric Analysis of Kidney Parenchyma Loss After Cryoablation vs Partial Nephrectomy 
Solomon Woldu*, Aaron Weinberg, Rashed Ghandour, Ruslan Korets, Irina Oyfe, Saravanan Krishnamoorthy, Ketan Badani, James McKiernan, New York, NY

Abstract: MP7-04
Introduction and Objectives
Small renal masses may be effectively managed by a variety of surgical strategies including partial nephrectomy (PN) and cryoablation (CA). We sought to determine differences in preservation of normal kidney parenchyma between these extirpative and ablative techniques using a novel 3-D imaging technique.Methods
Retrospective review of consecutive patients after PN or CA for stage T1a RCC who had both pre- and postoperative contrast-enhanced imaging available. Nephrometry scores were calculated by the R.E.N.A.L. system with lesions grouped by complexity levels: low (4-6), medium (7-9), and high (>9). 3-D rendering software was used to directly measure normal enhancing kidney parenchyma and tumor volumes preoperatively and postoperatively on surveillance imaging (see example image). Non-enhancing renal tissue (i.e. cysts or post-ablative lesions) were not included as functional kidney parenchyma. Renal function was calculated based on GFR closest to date of postoperative imaging.Results
82 patients were included in the analysis. 19 patients underwent CA (10 percutaneous, 19 laparoscopic), 53 underwent PN (18 open, 18 laparoscopic, 17 robotic). There were no differences in age, gender, BMI, co-morbidities, or pre-operative renal function between the groups. Tumor size was larger in the PN group than CA group, but there were more high-complexity tumors in the CA group. Although there was no difference in GFR change between the groups, PN was associated with a higher loss of enhancing kidney volume (-15%), than CA (-9%; p<0.05). Of the various approaches, robotic PN was associated with the largest postoperative decrease in kidney volume (21%; p<0.05), while percutaneous CA was associated with the smallest decrease in kidney volume (6%), despite the largest percentage of high complexity lesions.

Conclusions
Although the effects on short-term renal function did not differ between the groups, PN was associated with a higher degree of functional kidney parenchyma loss compared to CA. There was no association with GFR and surgical type or approach.

Date & Time: May 17, 2014 8:00 AM-10:00 AM
Session Title: Imaging/Radiology II
Sources of Funding: none

 

Saturday, May 17, 2014 8:00 AM-10:00 AM
OCCC: W 308
Imaging/Radiology II
Funding: None
MP7-12: Impact of pelvic biometric measurements, visceral and subcutaneous adipose tissue areas on trifecta outcomes and surgical margin status after open radical prostatectomy 
Sakir Ongun, Omer Demir*, Sinem Gezer, Ozgur Gurboga, Mustafa Secil, Izmir, Turkey

Abstract: MP7-12
Introduction and Objectives
In radical retropubic prostatectomy (RP) surgeons perform deep and narrow areas of the male pelvis which believed a challenging field, but there is no sufficient evidence to demonstrate that more challenging pelvic anatomy affect functional and oncological outcomes of RP. In this study we aimed to investigate the impact of pelvic biometric measurements, visceral and subcutaneous adipose tissue areas on trifecta outcomes (cancer control, continence, and potency) and surgical margin status after open RP.Methods
A retrospective study was performed on 270 patients who were diagnosed as clinically localized prostate cancer between 2005-2011 and had computed tomography imaging before RP operations. Pelvic bony and soft tissue measurements, the area of visceral and subcutaneous adipose tissue calculations were performed. Patients were evaluated for trifecta outcomes and surgical margin status on univariate and multivariate analyses. Subgroup analysis were performed for prostate volume, body mass index (BMI) and D’Amico risk classification.Results
Univariate analyzes revealed that patients with trifecta had lower PSA levels, wider symphysis angle, narrower width of prostate and soft tissue width, and younger (p<0.05). Univariate analyzes also revealed for patients with positive surgical margins they had higher PSA levels, lower prostate volume, narrower width of prostate and older (p<0,05). Visceral adipose tissue area were lower in patients with trifecta when BMI < 25 kg/cm2 (p< 0.05). In multivariate analyzes PSA level and symphysis angle were statistically significant for trifecta and only PSA level was statistically significant for positive surgical margins.(p<0.05)

Conclusions
Narrow symphysis angle is an independent risk factor for trifecta failure. Also higher visceral adipose tissue area in normal weight patients for BMI may have an impact for trifecta failure. In current era growing preferance of laparoscopic and robotic-assisted RP, pelvic measurements could also have an impact because the instruments are manipulated in a confined space, allowing limited freedom of movement during the surgery. Pelvic biometric measurements and visceral fat area might help preoperative planning and management of RP.

Date & Time: May 17, 2014 8:00 AM-10:00 AM
Session Title: Imaging/Radiology II
Sources of Funding: None

 

Saturday, May 17, 2014 8:00 AM-10:00 AM
OCCC: W 308
Imaging/Radiology II
Funding: Supported in part by The Joseph and Diane Steinberg Charitable Trust
MP7-15: A prospective comparative study of HistoscanningTM and multiparametric 3Tesla MRI for the prediction of cancer foci in men undergoing radical prostatectomy 
Clement Orczyk*, Andrew B Rosenkrantz, Fang-Ming Deng, James Wysock, New York City, NY, Jonathan Melamed, New York City, France, Samir S Taneja, New York City, NY

Abstract: MP7-15
Introduction and Objectives
Histoscanning (HS) is an ultrasound-based method using computer-aided analysis to assess tissue disorganization that has shown potential for prostate cancer detection in pilot studies. Our aim was to prospectively compare the ability of HS and multiparametric MRI (mpMRI) to predict the presence and location of cancer foci within the prostate among men undergoing robot-assisted radical prostatectomy (RP).Methods
31 consecutive men who underwent 3T pelvic phased-array coil mpMRI (T2WI, DWI, DCE) prior to RP were enrolled in an IRB-approved evaluation of HS. Following induction of anesthesia, HS was performed on each patient prior to incision for RP. HS, mpMRI, and step-section histology were independently reviewed with reviewers blinded to results of the other tests. The prostate was then divided into 8 regions of interest (ROI) and disease maps were generated for each modality. Data was then evaluated by a committee of 5 reviewers to determine concordance of reported lesions between each imaging modality and histology. Generalized estimating equations based on binary logistic regression were used to model concordance between modalities.Results
78/248 (31%) of ROIs were positive for cancer. Accuracy for detection of cancer within individual ROI was 82.6% and 65.3% for mpMRI and HS, respectively (p<0.001). While sensitivity by ROI did not differ between modalities (52.6% vs. 46.2%, P=0.3968), mpMRI was more specific (96.5% vs. 74.1%, p<0.0001). Within 78 positive ROI’s, 84 lesions were identified. The sensitivity for lesion detection was 50% for mpMRI, and 42.9% for HS (p=0.3768). Among lesions ≥10 mm (n=34), sensitivity was greater for mpMRI (82.4% vs 55.9%, p=.0352). Significant difference was noted for detection of lesions with Gleason score ≥7 (n=22; 86.4% vs. 50%; p=.0078) or primary Gleason grade ≥4 (n=6; 100% vs 33.3%, p=0.125). The overall PPV by lesion was 87.5% for mpMRI and 41.4% for HS (p<0.001). (e.g. figure1).

Conclusions
mpMRI showed greater accuracy in cancer detection both by ROI and individual lesion, due to superior specificity. Among individual lesions, both modalities showed relatively poor sensitivity, but mpMRI retained superior sensitivity for detection of larger, higher grade tumors. PPV was significantly better for mpMRI.

Date & Time: May 17, 2014 8:00 AM-10:00 AM
Session Title: Imaging/Radiology II
Sources of Funding: Supported in part by The Joseph and Diane Steinberg Charitable Trust

 

Saturday, May 17, 2014 8:00 AM-10:00 AM
OCCC: W 311 A
Urinary Diversion: Bladder Reconstruction, Augmentation, Substitution, Diversion
Funding: None
MP5-10: Robotic Intra-corporeal Orthotopic Neobladder during Radical Cystectomy: 132 Patients 
Mihir M. Desai*, Inderbir Gill, Los Angeles, CA, Abolfazl Hosseini, Tommy Nyberg, Christofer Adding, Oscar Laurin, Justin Collins, Stockholm, Sweden, Andre Luis Abreu, Alvin Goh, Monish Aron, Los Angeles, CA, Peter Wiklund, Stockholm, Sweden

Abstract: MP5-10
Introduction and Objectives
To present a 2-institutional experience with completely intra-corporeal robotic orthotopic neobladder and robotic radical cystectomy in 132 patients.Methods
Of 246 robotic intra-corporeal diversions, 132 were neobladders. All neobladders were constructed intra-corporeally in a globular configuration, completely duplicating established open surgical techniques. Demographics: mean age 60 years, BMI 27, female patients n=18 (14%), status-post neo-adjuvant chemotherapy n=30 (23%). Technical details: nerve-sparing in 56% of male patients, female organ-preserving in 32% of female patients; Lymphadenectomy: Extended (upto aortic bifurcation): n=51 (39%), Super-extended (upto IMA): n=20 (15%); Uretero-ileal anastomoses: Wallace-type (n=86; 65%), Bricker-type (n=46; 35%). Data were prospectively collected. Patients were retrospectively divided into chronologic groups to assess learning curve trends.Results
Mean data: OR time 7.6 hrs (4.4-13), blood loss 430 cc (50-2200), hospital stay 11 days (3-78). Complications: Clavien grade I, II, IIIa, IIIb, IV and V: Within 30 days: 7%, 25%, 9%, 4%, 2% and 0%; Between 30-90 days: 5%, 9%, 2%, 8%, 1% and 1.5%. Bowel complications: n=2 (1.5%) (ileo-neobladder fistula, bowel leak). Benign uretero-enteric strictures: n=5 (3.8 %). On comparing the initial 25 with the latest 32 patients, outcomes improved significantly: mean OR time (8.2 vs 7.3 hrs), blood loss (694 vs 319 cc) and hospital stay (12.6 vs 7.7 d). Positive surgical margin: n=1 (0.8%). Mean nodal yield: 29 (7-164), node-positivity rate was 17%. Over a mean follow-up of 2.1 years (0.1-9.8), cancer recurred in 20 patients (15%), 5-year overall, cancer-specific and recurrence-free survival was 72%, 72% and 71%, respectively.

Conclusions
Robotic intra-corporeal orthotopic neobladder diversion is now a developed and refined technique, diligently duplicating open principles. Operative efficiency and peri-operative outcomes have improved significantly with experience. Nodal yield, pathologic data and 5-year oncologic outcomes are equivalent to open surgery. As the next step, we propose a randomized controlled trial with open radical cystectomy/neobladder surgery, including objective assessment of functional outcomes.

Date & Time: May 17, 2014 8:00 AM-10:00 AM
Session Title: Urinary Diversion: Bladder Reconstruction, Augmentation, Substitution, Diversion
Sources of Funding: None

Source: AUA2014

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