“The influence of body mass index on the cost of radical prostatectomy for prostate cancer.”
Bolenz, C., A. Gupta, et al. (2010).
Study Type – Economic (cost impact) Level of Evidence 2b OBJECTIVE To evaluate the impact of obesity on the costs of robotic-assisted (RALP), laparoscopic (LRP) and open retropubic radical prostatectomy (RRP). PATIENTS AND METHODS The charts of 629 patients who underwent RP (262 RALP, 211 LRP and 156 RRP) between September 2003 and April 2008 at our institution were reviewed. Clinical and pathological data were collected, including age, American Society of Anesthesiologists score, body mass index (BMI), tumour stage, complications and length of stay. Direct and component costs (anaesthesia, laboratory, operating room service, radiology, room and board, pharmacy and surgical supplies) were obtained. Differences in costs were evaluated using three BMI categories (<25, normal weight; 25-<30, overweight; and >/=30 kg/m(2), obese). RESULTS Of 629 patients, 136 (21.6%) had normal weight, 320 (50.9%) were overweight, and 173 (27.5%) were obese. Clinical and pathological characteristics were similar in the three BMI categories of the entire cohort. The median direct cost was higher for obese patients (P= 0.035). On further stratification by type of RP, costs were higher amongst obese than the other groups undergoing LRP (median US$5703 vs $5347; P= 0.002) and RRP (median $4885 vs $4377; P= 0.004). In patients who underwent RALP there were no significant differences in direct costs (median $6761 in obese vs $6745 in non-obese; P= 0.64). CONCLUSION Obesity influenced the costs in patients who underwent LRP and RRP, mainly due to increased operating room service and anaesthesia costs in obese patients. RALP can be performed with no additional financial burden in obese patients.
“Shared medical appointments after cardiac surgery-the process of implementing a novel pilot paradigm to enhance comprehensive postdischarge care.”
Harris, M. D. (2010).
Journal of Cardiovascular Nursing 25(2): 124-129.
To facilitate the physical and emotional needs of patients undergoing cardiac surgery and their families, our Cardiac Surgery Outpatient Clinic at Cleveland Clinic, a nonprofit multispecialty academic medical center in Cleveland, Ohio, decided to implement a trial of a novel care delivery paradigm called Shared Medical Appointments (SMAs). The purpose of this venture was to facilitate timely access to care 3 to 5 days after hospital discharge, include family members in the education process and the care of the patient, and provide a forum for support and shared learning among patients who have been through like surgical experiences. The clinic system, which performed 3,597 open heart surgeries and 213 robotically assisted cardiac surgeries in 2008, already used family education classes to provide instruction to the patients and family prior to surgery. Because this medium was an effective way to disseminate knowledge, we theorized that using an SMA would be an effective strategy to provide timely medical care after discharge and garner support, education, and increased access to timely medical care after discharge. Although there were many physicians in subspecialties performing these types of clinic visits at our institution since 2002, by the spring of 2007, a group of cardiothoracic nurses decided to perform a trial on this model in this cohort of patients and be a fully nurse-led SMA to provide comprehensive care after discharge. Preliminary patient satisfaction surveys have revealed that 92% of post-cardiac surgery patients rated the experience as good or excellent, and 82% would prefer an SMA for their next clinic visit rather than an individual visit. These data are consistent with physician-led SMA satisfaction surveys in our organization to date. Although still in its relative infancy, an SMA for this cohort appears to have merit in enhancing the support and education as well as providing for the complex medical needs of these patients.
“Prostate cancer: Clinical practice guidelines in oncologyTM.”
Mohler, J., R. R. Bahnson, et al. (2010).
JNCCN Journal of the National Comprehensive Cancer Network 8(2): 162-200.
The intention of these guidelines is to provide a framework on which to base treatment decisions. Prostate cancer is a complex disease, with many controversial aspects of management and a dearth of sound data to support treatment recommendations. Several variables (including life expectancy, disease characteristics, predicted outcomes, and patient preferences) must be considered by patients and physicians when tailoring prostate cancer therapy to the individual patient. © Journal of the National Comprehensive Cancer Network.
“Health-related quality of life in men with localized prostate cancer: Review Article.”
Namiki, S. and Y. Arai (2010).
International Journal of Urology 17(2): 125-138.
With the established effectiveness of diverse treatments for localized prostate cancer, the identification of the physical and psychological consequences of the disease and its various treatments has become critical. In the present review, we aim to familiarize the reader with the methodologies of health-related quality of life (HRQOL) research and to review the recent literature on HRQOL outcomes in patients with localized prostate cancer. Studies have shown that prostate cancer and its treatment affect both disease-specific HRQOL (i.e. urinary, sexual, and bowel function) as well as general HRQOL (i.e. energy/vitality and performance in physical and social roles). However, these effects appear to differ according to the type of treatment, stage of disease, age of the subjects, time after treatment, and, more importantly, race or ethnicity. By including HRQOL in clinical decision-making, we can help our patients make more informed treatment choices for localized prostate cancer. © 2009 The Japanese Urological Association.
“The role of physician-patient communication in promoting patient-participatory decision making: Viewpoint.”
Ruiz-Moral, R. (2010).
Health Expectations 13(1): 33-44.
Context Involving patients in decision making (DM) is being advocated in clinical practice. For it to be operational, some behavioural models have been put forward. Yet, their suitability and implementation in primary care are controversial. Objective To illustrate: (i) some of the strategies general practitioners use to involve patients in DM and (ii) a type of patient involvement in the context of primary care based on the appropriate use of general communication skills along the physician-patient interaction to promote participation without an extensive exhibition of options. Strategy Analysis of two real situations of family medicine practice. Conclusion The quality of the process of involving patients in DM depends mainly on the professional’s communicative effort to achieve understanding and rapport rather than on an extensive discussion of possibilities or their prioritization. © 2009 Blackwell Publishing Ltd.
“The role of surgeons in identifying emerging technologies for health technology assessment.”
Stafinski, T., L. A. Topfer, et al. (2010).
Canadian Journal of Surgery 53(2): 86-92.
Background: Health technology assessment (HTA) is a tool intended to help policy-makers decide which technologies to fund. However, given the proliferation of newtechnologies, it is not possible to undertake an HTA of each one before it becomes funded. Consequently, “horizon-scanning” processes have been developed to identify emerging technologies that are likely to have a substantial impact on clinical practice. Although the importance of physicians in the adoption of new technologies is well recognized, their role in horizon scanning in Canada has been limited. The purpose of this project was to pilot an approach to engage physicians, specifically surgeons, in provincial horizon-scanning activities. Methods: We invited 18 surgeons from Alberta’s 2 medical schools to a horizon-scanning workshop to solicit their views on emerging technologies expected to impact surgical practice within the next 5 years and/or the importance of different attributes or characteristics of new technologies. Results: Surgeons, regardless of specialty, identified developments designed to enhance existing minimally invasive surgical techniques, such as endoscopic, robotic and image-guided surgery. Several nonsurgical areas, including molecular genetics and nano technology, were also identified. Of the 13 technology attributes discussed, safety or risk, effectiveness and feasibility were rated as most important. Lastly, participating surgeons expressed an interest in becoming further involved in local HTA initiatives. Conclusion: Surgeons, as adopters and users of health technologies, represent an important and accessible information source for identifying emerging technologies for HTA. A more formal, ongoing relationship between the government, HTA and surgeons may help to optimize the use of HTA resources.
“Endoscopic endonasal skull base surgery: past, present and future.”
Castelnuovo, P., I. Dallan, et al. (2010).
European Archives of Oto-Rhino-Laryngology 267(5): 649-663.
Endoscopic techniques have undergone tremendous advancement in the past years. From the management of phlogistic pathologies, we have learned to manage skull base lesions and even selected intracranial diseases. Current anatomical knowledge plus computer-aided surgery has enabled surgeons to remove large lesions in the paranasal sinuses extending beyond the boundaries of the sinuses themselves. In this sense, management of benign diseases via endoscopic routes is nowadays well accepted whilst the role of endoscopic techniques in sinonasal malignancies is still under investigation. Nowadays, it is possible to tackle different pathologies placed not only in the ventral skull base, but also extended laterally (infratemporal fossa and petrous apex) and even, in really selected cases, within the orbit. The ability to resect and reconstruct has improved significantly. At the moment, the improvement in surgical techniques, like the four-handed technique, has rendered endoscopic procedures capable of managing complex pathologies, according the same surgical principles of the open approaches. From now onwards, frameless neuronavigation, modular approaches, intraoperative imaging systems and robotic surgery are and will be an increasingly important part of endonasal surgery, and they will be overtaken by further evolution.
“Minimally invasive surgery and cancer: Controversies part 1.”
Goldfarb, M., S. Brower, et al. (2010).
Surgical Endoscopy and Other Interventional Techniques 24(2): 304-334.
Perhaps there is no more important issue in the care of surgical patients than the appropriate use of minimally invasive surgery (MIS) for patients with cancer. Important advances in surgical technique have an impact on early perioperative morbidity, length of hospital stay, pain management, and quality of life issues, as clearly proved with MIS. However, for oncology patients, historically, the most important clinical questions have been answered in the context of prospective randomized trials. Important considerations for MIS and cancer have been addressed, such as what are the important immunologic consequences of MIS versus open surgery and what is the role of laparoscopy in the staging of gastrointestinal cancers? This review article discusses many of the key controversies in the minimally invasive treatment of cancer using the procon debate format. Copyright © 2009 Springer Science+Business Media, LLC.
“Set-up and docking of the da Vinci surgical system: prospective analysis of initial experience.” Iranmanesh, P., P. Morel, et al. (2010).
Int J Med Robot 6(1): 57-60.
BACKGROUND: Set-up and docking of the da Vinci surgical system are assumed to extend overall operating times. We hypothesized that these tasks could be achieved in adequate times. Therefore, a prospective analysis of set-up and docking times of the da Vinci Surgical System was conducted. METHODS: We prospectively analysed set-up and docking times with the da Vinci surgical system in our division. RESULTS: Ninety-six patients were operated on over 30 months in our institution. Median set-up time was 22 (range 9-50) min and median docking time was 10 (range 2-70) min. Surgeons with previous docking experience were significantly faster than inexperienced surgeons: 8 (range 2-50) vs. 17.5 (range 10-70) min. Both set-up and docking showed a fast learning curve. CONCLUSION: The data support the conclusion that both set-up and docking of the robot can be achieved in adequate times and have a low impact on overall operating time.
“Does training on a virtual reality robotic simulator improve performance on the da Vinci surgical system?”
Lerner, M. A., M. Ayalew, et al. (2010).
Journal of Endourology 24(3): 467-472.
PURPOSE: The primary objective of this study is to determine if training on the Mimic dV-Trainer (MdVT) simulator results in improved ability on the da Vinci surgical system (dVSS) using exercises with inanimate objects. MATERIALS AND METHODS: Twelve trainees (MdVT group) and 10 residents and one fellow (dVSS group) were recruited for the study. Each participant in the MdVT group completed one session of five exercises on the dVSS that were scored for timing and accuracy, followed by four training sessions on the MdVT, and concluded with a final session on the dVSS in which the initial exercises were repeated. Improvement on the dVSS exercises was compared with dVSS group who completed four to six training sessions using the same exercises on the dVSS without any simulator training. RESULTS: Both groups had similar significant improvements in the Letter Board and String Running exercises for both timing and accuracy. The MdVT group demonstrated significant improvement in the Pattern Cutting and Peg Board times. Only the dVSS group significantly improved in the Knot Tying time and the Peg Board accuracy. CONCLUSION: Training with the MdVT provided similar improvement on five exercises performed on the dVSS when compared with training on the dVSS alone. The use of this simulator in resident and student training may help bridge the gap between the safe acquisition of surgical skills and effective performance during live robot-assisted surgery.
“Tensile Strength of Surgical Knots Performed with the da Vinci Surgical Robot.”
Reynisson, P., E. Shokri, et al. (2010).
Journal of Minimally Invasive Gynecology.
The objective of this study was to estimate the tensile strength of surgical knots made using the da Vinci robot. Four different types of flat square knots (strand-to-strand 4 throw, strand-to-strand 6 throw, loop-to-strand 4 throw, and loop-to-strand 6 throw) were made using the da Vinci-S system by 4 different surgeons, all experienced with the system. For the knots, we used braided polyglactin 910 (Vicryl 2-0). Hand-tied, flat, square, 4-throw strand-to-strand knots were used as reference. The tensile strength was measured for all knots using the Instron 5566 system calibrated to an accuracy of +/-.5% at 4 to 10 newtons (N) and +/-.4% at greater than 10 N. Compared with reference knots, only 1 of 4 surgeons could make knots as equally strong with the robot. For all surgeons, strand-to-strand knots had a significantly higher tensile strength than loop-to-strand knots when made with the robot. Adding 2 throws to the knot did not increase the knots strength in the robot. It is possible to make equally strong surgical knots with the da Vinci robot as by hand; however, despite previous experience with the robot, only 1 of 4 surgeons managed to do so. Adding 2 throws to R4SS and R4LS knots did not increase the tensile strength significantly for any of the 4 surgeons. It is important to train and tie knots using the da Vinci system with the same care as by hand and to be aware of possible differences in knot-tying technique with the robot and manually. With the robot, strand-to-strand knots were stronger than loop-to-strand knots, and should be preferred.
“Face Validation of a Novel Robotic Surgical Simulator.”
Seixas-Mikelus, S. A., T. Kesavadas, et al.
OBJECTIVES: To assess the face validity of Robotic Surgery Simulator (RoSS), a novel virtual reality training platform for the da Vinci Surgical System (DVSS). METHODS: Urologic surgeons, fellows, and residents attending the 2009 American Urologic Association Annual Meeting in April 2009 were invited to an orientation session with RoSS. Participants completed a questionnaire after orientation and two modules. RESULTS: Thirty participants including 24 surgeons and fellows experienced with robotic surgery and 6 robotic surgery novices participated in the study. Eighty percent participants had at least 4 years of experience with robotic surgery and 77% had performed an average of 340 cases on the DVSS as primary console surgeons. Subjects indicated that RoSS was realistically close to the DVSS console in terms of virtual simulation and instrumentation. Fifty-two percent of subjects rated RoSS somewhat close and 45% rated RoSS very close to the DVSS console. Thirty-seven percent rated RoSS pinch device somewhat close, and 47% very close to the DVSS. With regard to movement of the arms, 43% rated it somewhat close, 40% rated it very close, and 7% felt that it was just like the DVSS. Camera movement and clutch functions were rated not close (11%), somewhat close (57%), and very close (32%) to the DVSS. Data were further analyzed in terms of surgical volume. Thirty-eight percent of subjects had also tried the Mimic dV-Trainer robotic surgery simulator. CONCLUSIONS: RoSS provides opportunity for robot-assisted surgical training for future error-free surgery. Further validation will be necessary to assess RoSS and the application of specific modules for robot-assisted surgical training.
“Robotic assistance improves intracorporeal suturing performance and safety in the operating room while decreasing operator workload.”
Stefanidis, D., F. Wang, et al. (2010).
Surgical Endoscopy and Other Interventional Techniques 24(2): 377-382.
Background Intracorporeal suturing is one of the most difficult laparoscopic tasks. The purpose of this study was to assess the impact of robotic assistance on novice suturing performance, safety, and workload in the operating room. Methods Medical students (n = 34), without prior laparoscopic suturing experience, were enrolled in an Institutional Review Board-approved, randomized protocol. After viewing an instructional video, subjects were tested in intracorporeal suturing on two identical, live, porcine Nissen fundoplication models; they placed three gastrogastric sutures using conventional laparoscopic instruments in one model and using robotic assistance (da Vinci® ) in the other, in random order. Each knot was objectively scored based on time, accuracy, and security. Injuries to surrounding structures were recorded. Workload was assessed using the validated National Aeronautics and Space Administration (NASA) task load index (TLX) questionnaire, which measures the subjects’ self reported performance, effort, frustration, and mental, physical, and temporal demands of the task. Analysis was by paired t-test; p < 0.05 was considered significant. Results Compared with laparoscopy, robotic assistance enabled subjects to suture faster (595 ± 22 s versus 459 ± 137 s, respectively; p < 0.001), achieve higher overall scores (0 ± 1 versus 95 ± 128, respectively; p < 0.001), and commit fewer errors per knot (1.15 ± 1.35 versus 0.05 ± 0.26, respectively; p < 0.001). Subjects’ overall score did not improve between the first and third attempt for laparoscopic suturing (0 ± 0 versus 0 ± 0; p = NS) but improved significantly for robotic suturing (49 ± 100 versus 141 ± 152; p < 0.001). Moreover, subjects indicated on the NASA-TLX scale that the task was more difficult to perform with laparoscopic instruments compared with robotic assistance (99 ± 15 versus 57 ± 23; p < 0.001). Conclusions Compared with standard laparoscopy, robotic assistance significantly improved intracorporeal suturing performance and safety of novices in the operating room while decreasing their workload. Moreover, the robot significantly shortened the learning curve of this difficult task. Further study is needed to assess the value of robotic assistance for experienced surgeons, and validated robotic training curricula need to be developed. Copyright © 2009 Springer Science+Business Media, LLC.
“Robot-assisted anterior lumbar interbody fusion (ALIF) using retroperitoneal approach.”
Kim, M. J., Y. Ha, et al. (2010).
Acta Neurochirurgica 152(4): 675-679.
BACKGROUND: Over the past few years, robot-assisted surgery has become increasingly popular, affecting virtually all surgical fields. It has been proven to overcome pitfalls of laparoscopic procedures, such as high complication rates and steep learning curve. We have, therefore, performed experimental anterior lumbar interbody fusion (ALIF) using retroperitoneal approach in swine model to test the feasibility of robot-assisted surgery in spinal surgery. METHOD: In this report, we describe the setup with the da Vinci surgical system, operative method, result and discuss technical aspects and the future of robot-assisted ALIF. FINDINGS: Experimental retroperitoneal dissection using robotic surgical system was successfully performed with great visual cue, minimal retraction and minimal bleeding. CONCLUSION: Although retroperitoneal approach for spinal fusion has never been attempted with robotic surgical system, we could demonstrate the possibility with swine model. Further studies and development of appropriate instruments will bring minimally invasive spine surgery to a new