“Erectile dysfunction after radical prostatectomy: Pathophysiology, evaluation and treatment.”
Audouin, M., S. Beley, et al. (2010).
Dysfonction érectile après prostatectomie totale : physiopathologie, évaluation et traitement 20(3): 172-182.
Radical prostatectomy (RP) is the gold standard treatment for localized prostate cancer; yet erectile dysfunction (ED) in selected series is still reported as high as 80% after this surgery. Patient selection and surgical technique (i.e., preservation of neurovascular bundles) are the major determinants of postoperative ED. Pharmacological treatment of postoperative ED, using either oral or local approaches, is effective and safe. Thus, most men need adjuvant treatments to be sexually active following RP. These include intracorporeal injections of vasoactive drugs, vacuum constriction devices and transurethral dilators, all of which have reported response rates of 50 to 70%. Unfortunately, long-term compliance is sub-optimal, with a discontinuation rate of nearly 50% at 1 year. These non-oral options should be offered on an individual basis to patients who have failed oral therapy (IPDE5) since efficacy and compliance vary. Also, these options should be considered in the early postoperative period to enhance sexual activity and penile oxygenation, which may prevent corporeal fibrosis. Early penile rehabilitation with intracavernosal injections is the gold standard for partients over 60 years old and those who underwent non-sparing surgery. In younger patients and/or when preservation of nerve tissue was feasible, oral IPDE5 may be effective in promoting an earlier return of erectile function. Recent studies have shown that pharmacological prophylaxis early after RP can significantly improve the rate of erectile function recovery after surgery. Use of on-demand treatments for treatment of ED in patients subjected to RP has been shown to be highly effective, especially in cases of properly selected young patients treated with a bilateral nerve-sparing approach by experienced urologists. © 2009 Elsevier Masson SAS. All rights reserved.
“Indications and the Role of Laparoscopic Partial Nephrectomy.”
Bladou, F. (2010).
European Urology, Supplements 9(3): 454-458.
Context: Most renal cell carcinomas today are diagnosed incidentally at an early stage as small renal masses. Partial nephrectomy (PN) has become an established curative treatment in these indications and is mainly performed through open surgery. Objective: Laparoscopic PN (LPN) is an attractive alternative to open PN (OPN). In this article are reviewed the indications, the surgical specificities, and different options for standardisation and optimisation of LPN. Evidence acquisition: LPN should duplicate the principles of open surgery to get the same oncologic and complication outcomes. This is the case in experienced hands. Evidence synthesis: The role of LPN is, to date, restricted to high-volume laparoscopic centres. Indications should be adapted to each surgeon experience, keeping in mind that the goal of LPN is to safely remove a tumour with the lowest renal and surgical complications in a limited operative time to keep the warm ischemia time to <30 min. Surgical improvements and robot-assisted laparoscopy are two major aspects of the future development of LPN. Conclusions: LPN is a demanding surgical procedure and is so far limited to some specialised centres. New developments will potentially allow a wider use of this minimally invasive procedure. © 2010 European Association of Urology.
“Prostate cancer: The challenge of comparing open and laparoscopic surgery.”
Chamie, K. and M. S. Litwin (2010).
Nature Reviews Urology 7(3): 121-122.
“Surgery: Laparoscopic prostatectomy: Learning curve and cancer control.”
Chang, S. L. and M. L. Gonzalgo (2009).
Nature Reviews Urology 6(7): 361-362.
“Orgasmic dysfunction after open radical prostatectomy: Clinical correlates and prognostic factors.”
Dubbelman, Y., M. Wildhagen, et al. (2010).
Journal of Sexual Medicine 7(3): 1216-1223.
Introduction: Erectile function after radical retropubic prostatectomy (RRP) is extensively discussed in literature. However, less is known about orgasm after RRP. Aim: To analyze sexual function, in particularly orgasmic function, in men before and after RRP. Methods: Between 1977 and 2007 a RRP was performed in 1,021 men. All men were interviewed by their follow-up physician using a standardized interview about sexual function before and after RRP at regular intervals during a 2-year follow-up. The questions were related to sexual interest, sexual activity, spontaneous erections, and orgasmic function. Main Outcome Measures: Sexual function, in particularly orgasmic function, before and after RRP. Factors potentially influencing orgasmic function, such as patients age, type of operation, pathological stage and continence status were analyzed for their predictive value. Results: Information about preoperative and postoperative sexual activity and spontaneous erection was available in 596 and 698 men, respectively. Additional questions were asked on sexual interest (N = 425) and orgasmic function (N = 458).Pre-operatively, sexual interest, sexual activity, spontaneous erections and orgasmic function were normal in 99%, 82.1%, 90.0% and 90% of men, respectively. After operation these values decreased to 97.2%, 67.3%, 29.4% and 66.8%, respectively. Orgasmic function was preserved in 141 of 192 men (73.4%) after a bilateral nerve sparing procedure, in 90 out of 127 men (70.9%) after a unilateral nerve-sparing procedure and in 75 of 139 men (54.0%) after non-nerve sparing technique. Postoperatively, orgasm was present in 123 (77.4%) men below the age of 60 years and in 183 (61.2%) men of 60 years and older (P < 0.0001). Orgasmic function was significantly affected by age ≥60 years, non-nerve sparing procedure and severe incontinence (more than two pads/day). Conclusions: After RRP, orgasmic function is still present in the majority of men. A non-nerve sparing operation, age, and severe urinary incontinence are risk factors for orgasmic dysfunction after RRP. © 2009 International Society for Sexual Medicine.
“Staple line reinforcement in laparoscopic bariatric surgery: does it actually make a difference? A systematic review and meta-analysis.”
Giannopoulos, G. A., N. E. Tzanakis, et al. (2010).
“Systemic bias in peer Review: Suggested causes, potential remedies.”
Kadar, N. (2010).
Journal of Laparoendoscopic and Advanced Surgical Techniques 20(2): 123-128.
Objective: The aim of this study was to determine if peer review conducted under real-world conditions is systematically biased. Study Design: A repeated-measures design was effectively created when two board-certified obstetrician-gynecologists reviewed the same 26 medical records of patients treated by the same physician, and provided written evaluations of each case and a summary of their criticisms. The reviews were conducted independently for two different, unaffiliated hospitals. Neither reviewer was aware of the other’s review, and neither was affiliated with either hospital or knew the physician under review. This study reports the degree of agreement between the two reviewers over the care rendered to these 26 patients. Results: Three of the 26 cases reviewed had complications. Both reviewers criticized these cases, but criticized 2 of them for different reasons. At least one of the reviewers criticized 14 (61%) of the 23 uncomplicated cases, about which no quality concerns had been raised prior to the review. With one exception, they criticized completely different cases and criticized this 1 case for different reasons. Thus, only 4 of the 17 cases criticized by at least one of the reviewers were criticized by both of them, and only 1 of the 4 cases were criticized for the same reason. The Kappa statistic was -0.024, indicating no agreement between the reviewers (P=0.98). Conclusions: As presently conducted, peer review can be systematically biased even when conducted independently by external reviewers. Dual-process theory of reasoning can account for the bias and predicts how the bias may potentially be eliminated or reduced. Copyright 2010, Mary Ann Liebert, Inc.
“Continence Definition After Radical Prostatectomy Using Urinary Quality of Life: Evaluation of Patient Reported Validated Questionnaires.”
Liss, M. A., K. Osann, et al. (2010).
Journal of Urology 183(4): 1464-1468.
Purpose: After radical prostatectomy continence is commonly defined as no pads except a security pad or 0 to 1 pad. We evaluated the association of pad status and urinary quality of life to determine whether security and 1 pad status differ from pad-free status to better define 0 pads as the post-prostatectomy standard. Materials and Methods: A total of 500 consecutive men underwent robot assisted radical prostatectomy from October 2003 to July 2007. Data were collected prospectively and entered into an electronic database. Postoperatively men completed self-administered validated questionnaires including questions on 1) daily pad use (0, security, 1, or 2 or more), 2) urine leakage (daily, about once weekly, less than once weekly or not at all), 3) urinary control (none, frequent dribbling, occasional dribbling or total control), 4) American Urological Association symptom score and 5) urinary quality of life. Results: Postoperatively men who indicated 0 pad use had a mean ± SE symptom score of 5.8 ± 0.3 and pleased quality of life (1.16 ± 0.08). In contrast, men with a security pad and 1 pad had a symptom score of 7.6 ± 0.7 and 9.2 ± 0.6 but mixed quality of life (2.78 ± 0.18 and 3.41 ± 0.15, respectively, p <0.0005). Conclusions: Results show a significant decrease in quality of life between no pads (1.16 or pleased), a security pad and 0 or 1 pad (2.78 and 3.41 or mixed, respectively). Findings do not support defining continence with a security pad or 0 to 1 pad. Continence should be strictly defined as 0 pads. © 2010 American Urological Association Education and Research, Inc.
“Laparoscopic surgery for gynaecological cancers in obese women.”
Martinek, I. E., K. Haldar, et al. (2010).
Maturitas 65(4): 320-324.
The use of laparoscopic surgery in the management of gynaecological malignancies has been growing for over a decade. Concomitantly the incidence of obesity has been increasing worldwide. This review summarizes the available studies on minimal invasive surgery in obese women with gynaecological malignancies. We undertook a literature search to identify the differences between traditional open methods and the laparoscopic approach in terms of intra- and postoperative outcome and patient safety. Only eight relevant studies were identified. Six of these focused on endometrial cancer, one study included early stage cervical and ovarian cancers with other benign conditions, while another paper included cervical and endometrial pre-cancers and only a few malignant conditions. Obesity is generally known to increase the risk of intra- and postoperative complications. However, several studies show that obesity, formerly precluding keyhole surgery, seems now to be an indication for the laparoscopic approach. As compared to laparotomy, laparoscopic surgery has a good postoperative outcome, reduced estimated blood loss (EBL) and pain and in some series an increased lymph node count. Laparoscopy has been shown to be cost effective with a shorter hospital stay and return to normal activity. Survival is reported to be the same with both laparotomy and laparoscopy. The benefits of minimal invasive surgery in gynaecological surgery are starting to be found with robotic surgery.
“Outcome measures for surgical simulators: Is the focus on technical skills the best approach?”
Pugh, C., S. Plachta, et al. (2010).
Surgery 147(5): 646-654.
Background: Mastery of operative performance is based on technical skill and intra-operative judgment. However, previous simulation studies have largely focused on technical skills and measures. This study investigates changes in operative performance when assessment and feedback focus on decision making. Methods: Using a nonequivalent, pretest/post-test experimental design, 8 senior residents (PGY4-5) performed a laparoscopic ventral hernia repair using a newly developed box-trainer style simulator fabricated to induce surgical decision making. The pretest simulator had a 10 × 10-cm defect 5 cm above the umbilicus. The post-test simulator had a 10 × 10-cm defect in the right upper quadrant. After the pretest, faculty provided immediate feedback on operative decisions that lead to errors. In addition, residents were allowed to visually inspect their repair by removing the box trainer skins. Video-analysis using a 9-item decision making checklist was used to categorize pretest and post-test error differences. Results: Common errors made during the pretest included improper visualization of the suture passer and improper mesh preparation on the back table. These errors resulted in incomplete hernia repairs by 75% of residents on the pretest. In contrast, 100% of residents successfully completed the more difficult, nonequivalent post-test hernia. Checklist analysis showed residents committed more errors on the pretest resulting in lower performance scores (score = 48.12; SD = 19.26) compared with post-test performance (score = 75.00; SD = 14.39; P < .05). Conclusion: Residents’ decision-making skills seem to significantly affect operative performance. To facilitate mastery of operative performance, additional research is needed on simulation-based, operative skills measures that focus on intra-operative decision making. © 2010 Mosby, Inc. All rights reserved.
“Da Vinci System: clinical experience with complex proximal humerus fractures.”
Russo, R., V. Visconti, et al. (2010).
Chirurgia degli Organi di Movimento 94 Suppl 1: S57-64.
The purpose of this study is to report the clinical and radiographic outcomes after open reduction and internal fixation of displaced proximal humerus fractures with the “Da Vinci System”. It is a triangle-shaped cage whose opposite faces are pierced, and it represents the evolution of a triangle-shaped bone block technique performed in a previous series of 33 patients. The new device is an interesting innovation to treat the difficult problem of fracture fragments reconstruction and stability, metaphyseal bone loss and proximal humerus revascularization. According to the technique, authors position the correct size titanium cage into the metaepiphysis, so that the fragments are reduced upon the cage, and they are stabilized with a minimal osteosynthesis by Kirschner wires, titanium screws or transosseous sutures. If the fracture line involves the proximal portion of the diaphysis, it is possible to use a short low profile plate. Between May 2005 and November 2009, we treated 71 patients (34 men and 37 women), even though we included in our study only 59 patients, who had a minimum follow-up of 12 months. The first patient has been treated in May 2005 and the last one in September 2008. The mean age was 60.8 years (minimum 27, maximum 78). There were 8 displaced 3-part fractures, 20 displaced 4-part fractures, 10 4-part fracture-dislocations, 5 head splitting, 12 unclassified multifragmentary fractures, 1 2-part fracture with multifragmentary calcar and 3 malunions of 4-part fracture. The functional results were evaluated by the Constant score. With a mean follow-up of 24 months (minimum 12, maximum 36 months), the mean Constant score was 80.25. The results were excellent or good in 48 cases, bad in 2 cases and satisfactory in 9; the mean active anterior elevation (AAE) was 160 degrees . All fractures but one healed; in one case, we had a deep infection after 80 days since the operation, treated with a preformed cement spacer.
“Early-stage cervical cancer: Is surgery better than radiotherapy?”
Undurraga, M., P. Loubeyre, et al. (2010).
Expert Review of Anticancer Therapy 10(3): 451-460.
Patients with early-stage cervical cancer may be treated appropriately with either radical surgery or radiation therapy. As most patients will be cured of their disease, side-effects of therapy and quality of life become of great importance. Individualization of treatment to reduce therapy-associated morbidity should be the main goal in cervical cancer management. Recent developments in surgical techniques, such as laparoscopy, nerve-sparing radical hysterectomy, sentinel lymph node biopsy, trachelectomy and ‘less radical’ hysterectomy, have contributed to reduce the morbidity of the surgical treatment. The use of postoperative radiotherapy or chemoradiation leads to more pronounced side effects than after either surgery or irradiation alone. Therefore, prognostic factors should be used to select patients for either surgery or radiotherapy alone to minimize the increased toxicities associated with the combination. The objectives of this review are to discuss the evidence supporting radical surgery, ‘less radical’ surgery and radiotherapy with regard to complication rate and quality of life. © 2010 Expert Reviews Ltd.
“Methodologies for establishing validity in surgical simulation studies.”
Van Nortwick, S. S., T. S. Lendvay, et al. (2010).
Surgery 147(5): 622-630.
Background: Validating assessment tools in surgical simulation training is critical to objectively measuring skills. Most reviews do not elicit methodologies for conducting rigorous validation studies. Our study reports current methodological approaches and proposes benchmark criteria for establishing validity in surgical simulation studies. Methods: We conducted a systematic review of studies establishing validity. A PubMed search was performed with the following keywords: “validity/validation,” “simulation,” “surgery,” and “technical skills.” Descriptors were tabulated for 29 methodological variables by 2 reviewers. Results: A total of 83 studies were included in the review. Of these studies, 60% targeted construct, 24% targeted concurrent, and 5% looked at predictive validity. Less than half (45%) of all the studies reported reliability data. Most studies (82%) were conducted in a single institution with a mean of 37 subjects recruited. Only half of the studies provided rationale for task selection. Data sources included simulator-generated measures (34%), performance assessment by human evaluators (33%), motion tracking (6%), and combined modes (28%). In studies using human evaluators, videotaping was a common (48%) blinding technique; however, 34% of the studies did not blind evaluators. Commonly reported outcomes included task time (86%), economy of motion (51%), technical errors (48%), and number of movements (25%). Conclusion: The typical validation study comes from a single institution with a small sample size, lacks clear justification for task selection, omits reliability reporting, and poses potential bias in study design. The lack of standardized validation methodologies creates challenges for training centers that survey the literature to determine the appropriate method for their local settings. © 2010 Mosby, Inc. All rights reserved.
“American Cancer Society Guideline for the Early Detection of Prostate Cancer: Update 2010.”
Wolf, A. M. D., R. C. Wender, et al. (2010).
CA: A Cancer Journal for Clinicians 60(2): 70-98.
“New technology offers a gentle touch for cancer surgery. A new robotic surgical tool may detect tumors far more accurately than current minimally invasive techniques.”
DukeMedicine healthnews 15(12): 5-6.
“Robotics versus laparoscopy – an experimental study of the transfer effect in maiden users.”
Anderberg, M., J. Larsson, et al. (2010).
Annals of Surgical Innovation and Research: 3.
Background: Robot-assisted laparoscopy (RL) is used in a wide range of operative interventions, but the advantage of this technique over conventional laparoscopy (CL) remains unclear. Studies comparing RL and CL are scarce. The present study was performed to test the hypothesis that maiden users master surgical tasks quicker with the robot-assisted laparoscopy technique than with the conventional laparoscopy technique. Methods: 20 subjects, with no prior surgical experience, performed three different surgical tasks in a standardized experimental setting, repeated four times with each of the RL and CL techniques. Speed and accuracy were measured. A cross-over technique was used to eliminate gender bias and the experience gained by carrying out the first part of the study. Results: The task “tie a knot” was performed faster with the RL technique than with CL. Furthermore, shorter operating times were observed when changing from CL to RL. There were no time differences for the tasks of grabbing the needle and continuous suturing between the two operating techniques. Gender did not influence the results. Conclusion: The more advanced task of tying a knot was performed faster using the RL technique than with CL. Simpler surgical interventions were performed equally fast with either technique. Technical skills acquired during the use of CL were transferred to the RL technique. The lack of tactile feedback in RL seemed to matter. There were no differences between males and females.
“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. © 2010, Mary Ann Liebert, Inc.
“System architecture for workflow controlled robotic surgery.”
Mönnich, H., D. Botturi, et al. (2009).
Journal on Information Technology in Healthcare 7(6): 345-352.
Objective: To develop a control workflow system that can be used with any surgical robotic system. The system will connect different devices inside the operating theatre and enable visualisation of the planning and execution of a surgical workflow. Methods: The workflow was developed using Petri Nets in extensible markup language (XML). Petri Nets have been chosen because they are mathematically well proven and support formal semantic and structural checking and analysing tools. The XML data can easily be analysed with XMLSchema for correct structure and syntax. The workflow for the surgical intervention is transformed into an executable statechart representation. All hardware and software parts are modeled as software components. The communication is implemented with realtime CORBA (Common Object Request Broker Architecture). The system was tested using a demonstrator consisting of 2 robots (one acting as a motion simulator), a laser distance sensor and an optical tracking system. Results: Performance analysis confirmed the feasibility of the system. It is possible to read the data from the laser distance sensor with a 1ms update rate and control the hardware with a 12ms update rate. The workflow provides easy to understand visualisation with extended check opportunities to detect wrongly constructed workflows. Conclusion: The devised system is feasible for implementation in the safety critical field of surgical interventions. © The Journal on Information Technology in Healthcare.
“Robotic eye surgery.”
Hubschman, J. P., J. Wilson, et al. (2010).
Ophthalmology 117(4): 857