Abstrakt Ostatní Květen 2011

Dovolujeme si Vás upozornit na sborník abstrakt z kongresu ASCRS (American Society of Colon and Rectal Surgeons), který se konal  14.-19.5.2011 v Kanadě. Soubor je ke stažení zde (PDF)


“Impact of annual surgical volume on length of stay in patients undergoing minimally invasive prostatectomy: A population-based study.”
Budäus, L., M. Morgan, et al. (2011).
European Journal of Surgical Oncology 37(5): 429-434.

Background: On average, patients remain hospitalized no more than 2 days after MIRP. The aim of our study was to examine the temporal trends in length of stay ≥3 days and to test the relationship between annual surgical volume (ASV) and annual hospital volume (AHV) and length of stay ≥3 days in patients undergoing MIRP. Material and methods: Within the Florida Hospital Inpatient Datafile, 2439 men who were treated with MIRP for prostate cancer between 2005 and 2008 were identified. Temporal trends were assessed and uni and multi-variable logistic regression models tested the relationship between ASV, AHV and length of stay ≥3 days. Results: The average length of stay decreased from 2.4 in 2005 to 1.7 days in 2008. Length of stay ≥3 days was recorded in 13.6% of patients and the proportion of patients staying more than ≥3 days decreased over time (25.5-12.2%; Chi Square trend p < 0.001). After stratification into low (<1-15 MIRPs) vs. intermediate (16-63 MIRPs) vs. high ASV tertiles (≥64 MIRPs) the proportion of patients with length of stay ≥3 days were 29.1; 13.2 and 11.1%. In multivariable logistic regression models predicting length of stay ≥3 days, ASV, year of surgery and comorbidities achieved independent predictor status and MIRP patients operated by highest ASV tertile surgeons were 71% (p < 0.001) less likely to be hospitalized for more than 3 days. Conclusion: The length of stay after MIRP decreased between 2005 and 2008. Surgical expertise represented one of the main determinants of shorter length of stay. © 2011 Elsevier Ltd. All rights reserved.

“Robotic high-intensity focused ultrasound for prostate cancer: What have we learned in 15 years of clinical use?”
Chaussy, C. G. and S. F. Thüroff (2011).
Current Urology Reports 12(3): 180-187.

High-intensity focused ultrasound (HIFU) is an emerging, noninvasive, local treatment of prostate cancer with 15 years of clinical experience, during which about 30,000 HIFU treatments have been performed worldwide. In this paper, we review relevant publications regarding the means by which new and old prostate cancer technologies are evaluated, the outcomes of HIFU by Ablatherm (EDAP TMS, Lyon, France), and the evolution currently underway regarding how prostate cancer is diagnosed and treated. We show the potential of HIFU to be used as local therapy for men with any stage of prostate cancer and how this additional therapeutic option can fit within the future armamentarium of a sequential multimodal therapy concept. © 2011 Springer Science+Business Media, LLC.

“Active surveillance vs. treatment for low-risk prostate cancer: A cost comparison.”
Eldefrawy, A., D. Katkoori, et al. (2011).
Urol Oncol.

OBJECTIVE: Radical prostatectomy (RP) and radiation therapy are standard curative approaches for low-risk prostate cancer (PC). Active surveillance (AS) is becoming an increasingly accepted management alternative for low-risk PC. Our aim is to compare the cumulative medical costs of treatment vs. AS. METHODS AND MATERIALS: We collected data on the cumulative medical costs of open radical retropubic prostatectomy (RRP), robotic-assisted radical prostatectomy (RARP), external beam radiotherapy (EBRT), brachytherapy (BT), and AS at our institution. For physicians’ reimbursements, Medicare values of our region were used to maintain uniformity. For inpatient costs other than reimbursements, we used the mean cost at our institution. The costs of RRP and RARP involve preoperative investigations, medical clearance, physicians’ fees, inpatient costs, and pathologic examination of prostatectomy specimen and follow-up. The inpatient costs include the operating room, disposable equipment, anesthesia, post-anesthesia care, transfusion, and hospital stay. The cost of EBRT involves the cost of consultation, planning, simulation and treatment sessions, and follow-up. BT costs involved radiotherapy planning as well as inpatients costs. AS protocol involves regular visits, transrectal ultrasound guided biopsies, prostate specific antigen (PSA) testing. To evaluate the cost of treating complications, treatment after AS, and treatment for recurrence, we created a Markov model based on recent studies and our experience. RESULTS: The cumulative costs of RRP are $9,732 (1 year), $10,360 (2 years), $12,209 (5 years), and $15,084 (10 years). While for RARP, the costs are $17,824 (1 year), $18,308 (2 years), $20,117 (5 years), and $22,762 (10 years). The costs of EBRT are $20,730 (1 year), $20,969 (2 years), $22,043 (5 years), and $23,953 (10 years). BT costs are $14,061 (1 year), $14,300 (2 years), $15,374 (5 years), and $17,284 (10 years). The costs of AS are $1,154 (1 year), $2,308 (2 years), $8,761 (5 years), and $13,116 (10 years). CONCLUSIONS: The cumulative medical costs of RARP and EBRT are much higher than BT, RRP, and AS. AS is associated with a different cost distribution in which the initial cost is low and relatively higher cost of follow-up. Despite the higher follow-up cost, AS remains the most cost effective alternative for low-risk PC.

“Radical perineal prostatectomy: A learning curve?”
Eliya, F., K. Kernen, et al. (2011).
International Urology and Nephrology 43(1): 139-142.

Objective: To determine a learning curve for radical perineal prostatectomy after formal training in radical retropubic prostatectomy. Methods: Using the William Beaumont Hospital Prostatectomy database, we analyzed peri-operative data from two surgeons performing radical perineal prostatectomies from their initial 96 cases to determine a learning curve. Results: Over time, data between the first and last quarters showed consistent, excellent results in terms of skin time (143 SD ± 22 and 136 SD ± 24 min), blood loss (310 SD ± 120 and 335 ± 216 cc), and length of stay (1.3 SD ± 0.6 and 1.2 SD ± 0.5 days), without significant change. However, only two positive margins were obtained in the 4th quartile representing a significant change and possibly representing a learning curve. Conclusions: These data show that excellent, reproducible results can be obtained using basic surgical principles, without incorporating expensive technology and resources. © 2010 Springer Science+Business Media, B.V.

“Lymph node counts in endometrial cancer: expectations versus reality.”
Euscher, E. D., R. Bassett, et al. (2011).
American Journal of Surgical Pathology 35(6): 913-918.

It has been proposed that an adequate lymph node (LN) dissection in cases of endometrial carcinoma (CA) should contain a determined number of pelvic (P) and/or para-aortic (PA) LNs. As a result, our surgeons have certain expectations regarding the number of PLNs and PALNs reported per case. Failure to meet these expectations has become a challenge in our practice. In an attempt to solve this problem, we wanted to ascertain whether a pathology factor such as disregarding small LNs not detected on gross examination was responsible for any discrepancy between expected and reported LN counts. To achieve this goal, we evaluated the impact of the microscopic examination of residual adipose tissue (AT) after the routine processing of LN dissections performed as part of the staging procedure for patients with endometrial CA (endometrioid, serous, and clear cell CA) on the LN counts and status for hysterectomies performed from 2006 to the present. In addition, we assessed whether other factors such as surgical procedure type, operating surgeon, histologic subtype of CA, depth of myometrial invasion, or body mass index had an impact on the number of LNs obtained. The number of PLNs and PALNs were recorded. All LN specimens were processed by dissecting LNs from the surrounding AT. The number of LNs submitted per cassette was recorded in the section code. In cases in which residual AT was submitted, hematoxylin and eosin-stained slides of the additional tissue were reviewed to determine the number and size of any additional LNs and their status. Two hundred fifty-eight patients had a median of 11 PLNs (range, 1 to 38) and 6 PALNs (range, 1 to 25). Fifty of 78 cases (64%) in which residual AT was submitted had additional LNs (median size, 4.0 mm): median 2 PLNs and 3 PALNs. There was no significant association between the number of LNs obtained and whether the residual AT was submitted (PLN, P=0.2; PALN, P=0.78). There were no cases in which metastatic endometrial CA was present exclusively in the additional LNs. Compared with open hysterectomy, laparoscopically and robotically obtained lymphadenectomy specimens had an average of 3 and 0.8 more PALNs, respectively (P=0.002). No similar association was found for PLNs or total LNs. Evidence for some difference in LN counts between surgeons was observed. No evidence of an association between body mass index, histologic subtype of endometrial CA or depth of myometrial invasion and LN count was identified. In our experience, the standard processing of lymphadenectomy specimens adequately reflects the actual numbers of LNs obtained in cases of endometrial CA. Submitting the residual AT does not increase the number of reported LNs or the detection of positive LNs. Additional studies are required to determine the actual numbers of PLNs and PALNs present and to determine whether a revision of the number of LNs required to consider a lymphadenectomy as adequate is necessary.

“Cost-effectiveness analyses of laparoscopic versus open surgery.”
Hottenrott, C. (2011).
Surgical Endoscopy and Other Interventional Techniques 25(3): 990-992.

“Challenges of interpreting and improving radical prostatectomy outcomes: Technique, technology, training, and tactical reporting.”
Hu, J. C., H. Y. Yu, et al. (2011).
European Urology 59(6): 1073-1074.

“Update on prostate brachytherapy: Long-term outcomes and treatment-related morbidity.”
Kao, J., J. A. Cesaretti, et al. (2011).
Current Urology Reports 12(3): 237-242.

Current research in prostate brachytherapy focuses on five key concepts covered in this review. Transrectal ultrasound-guided prostate brachytherapy assisted by intraoperative treatment planning is the most advanced form of image-guided radiation delivery. Prostate brachytherapy alone for low-risk prostate cancer achieves lower prostate-specific antigen (PSA) nadirs than intensity-modulated radiotherapy (IMRT) or protons while maintaining durable biochemical control in about 90% of patients without late failures seen in surgically treated patients. As an organ-conserving treatment option, seed implant results in a lower rate of erectile dysfunction and urinary incontinence than surgery that has been validated in several recent prospective studies. Combined IMRT and seed implant has emerged as a rational and highly effective approach to radiation-dose escalation for intermediate- and high-risk prostate cancer. Preliminary results suggest that seed implantation may play a role in improving outcomes for historically poor-prognosis locally advanced and recurrent prostate cancers. © 2011 Springer Science+Business Media, LLC.

“Age at surgery, educational level and long-term urinary incontinence after radical prostatectomy.”
Nilsson, A. E., M. C. Schumacher, et al. (2011).
BJU International.

Study Type – Harm (case series) Level of Evidence 4 What’s known on the subject? and What does the study add? Several factors including age, body mass index (BMI), prostate size and previous transurethral resection of the prostate have been suggested to play a part in determining the risk of urinary incontinence after radical prostatectomy. Results relating to the importance of each factor have been conflicting, so we need more data to be able to identify the relevant factors. In this consecutive series with information from 1179 patients who had undergone radical prostatectomy, age at the time of surgery, educational level, respiratory disease and salvage radiation therapy predicted the occurrence of long-term urinary incontinence. Increasing age predicted the risk in an exponential manner, and the data indicate a correlation across all educational levels. There was no certain association between previous transurethral resection of the prostate, increased BMI or prostate size and urinary incontinence. OBJECTIVE: * To identify predictors for long-term urinary leakage after radical prostatectomy. PATIENTS AND METHODS: * A consecutive series of 1411 patients who underwent radical prostatectomy (open surgery or robot-assisted laparoscopic surgery) at Karolinska University Hospital between 2002 and 2006 were invited to complete a study-specific questionnaire. * Urinary leakage was defined as use of two or more pads per day. RESULTS: * Questionnaires were received from 1288 (91%) patients with a median follow-up of 2.2 years. Age at surgery predicts in an exponential manner long-term urinary incontinence at follow-up with an estimated relative increase of 6% per year. * Among the oldest patients, 19% had urinary incontinence compared with 6% in the youngest age group, translating to a prevalence ratio of 2.4 (95% confidence interval [CI], 1.5-8.1). * Low educational level, as compared with high, yielded an increased age-adjusted prevalence ratio of 2.5 (95% CI, 1.7-3.9). * Patients who had undergone salvage radiation therapy had an increased prevalence of urinary incontinence (2.5; 95% CI, 1.6-3.8), as did those with respiratory disease (2.4; 95% CI, 1.3-4.4). * Body mass index, prostate weight, presence of diabetes or previous transurethral resection did not appear to influence the prevalence of urinary incontinence. CONCLUSIONS: * In this series, a patient’s age at radical prostatectomy influenced, in an exponential manner, his risk of long-term urinary incontinence. * Other predictors are low educational level, salvage radiation therapy and respiratory disease. * Intervention studies are needed to understand if these data are relevant to the prevalence of urinary leakage if a radical prostatectomy is postponed in an active monitoring programme.

“Identifying Ureteropelvic Junction Obstruction by Fluorescence Imaging: A Comparative Study of Imaging Modalities to Assess Renal Function and Degree of Obstruction in a Mouse Model.”
Penna, F. J., J. S. Chow, et al. (2011).
Journal of Urology.

Purpose: Radiological imaging is the mainstay of diagnosing ureteropelvic junction obstruction. Current established radiological modalities can potentially differentiate the varying degrees of obstruction but they are limited in functionality, applicability and/or comprehensiveness. Of particular concern is that some tests require radiation, which has long-term consequences, especially in children. Materials and Methods: We investigated the novel use of GenhanceTM 680 dynamic fluorescence imaging to assess ureteropelvic junction obstruction in 20 mice that underwent partial or complete unilateral ureteral obstruction. Ultrasound, mercaptoacetyltriglycine renography, magnetic resonance imaging and fluorescence imaging were performed. Results: Our model of partial and complete obstruction could be distinguished by ultrasound, mercaptoacetyltriglycine renography and magnetic resonance imaging, and was confirmed by histological analysis. Using fluorescence imaging distinct vascular and urinary parameters were identified in the partial and complete obstruction groups compared to controls. Conclusions: Fluorescence imaging is a feasible alternative radiological imaging modality to diagnose ureteropelvic junction obstruction. It provides continuous, detailed imaging without the risk of radiation exposure. © 2011 American Urological Association Education and Research, Inc.

“Learning curve for radical retropubic prostatectomy.”
Saito, F. J. A., M. F. Dall’Oglio, et al. (2011).
International Braz J Urol 37(1): 67-74.

Purpose: The learning curve is a period in which the surgical procedure is performed with difficulty and slowness, leading to a higher risk of complications and reduced effectiveness due the surgeon’s inexperience. We sought to analyze the residents’ learning curve for open radical prostatectomy (RP) in a training program. Materials and Methods: We conducted a prospective study from June 2006 to January 2008 in the academic environment of the University of São Paulo. Five residents operated on 184 patients during a four-month rotation in the urologic oncology division, mentored by the same physician assistants. We performed sequential analyses according to the number of surgeries, as follows: ≤ 10, 11 to 19, 20 to 28, and ≥ 29. Results: The residents performed an average of 37 RP each. The average psa was 9.3 ng/mL and clinical stage T1c in 71% of the patients. The pathological stage was pT2 (73%), pT3 (23%), pT4 (4%), and 46% of the patients had a Gleason score 7 or higher. In all surgeries, the average operative time and estimated blood loss was 140 minutes and 488 mL. Overall, 7.2% of patients required blood transfusion, and 23% had positive surgical margins. Conclusion: During the initial RP learning curve, we found a significant reduction in the operative time; blood transfusion during the procedures and positive surgical margin rate were stable in our series.

“Is early stage endometrial cancer safely treated by laparoscopy? Complications of a multicenter study and review of recent literature.”
Tinelli, R., M. Malzoni, et al. (2011).
Surgical Oncology 20(2): 80-87.

Background: To compare the complications after total laparoscopic hysterectomy (LPS) and abdominal hysterectomy with lymphadenectomy (LPT) for early stage endometrial cancer in a series of 226 women and to assess the disease-free survival and the recurrence rate. Patients and methods: Two hundred and twenty six patients with clinical stage I endometrial cancer were enrolled in a multicenter study and underwent surgical staging consisting of inspecting the intraperitoneal cavity, peritoneal washing, total hysterectomy, bilateral salpingo-oophorectomy, and in all cases we performed systematic bilateral pelvic lymphadenectomy by LPS or LPT approach. Results: One patient of the LPS group had an uretero-vaginal fistula and another patient had an ureteral stricture temporarily treated with a stent. One patient of the LPS group had a bowel perforation due to dense adhesions with the peritoneum under the umbilicus, resolved with a bowel resection and an end-to-end anastomosis. In three patients of the LPS group we observed a vaginal cuff dehiscence and in one case a pelvic lymphocyst was reported. Conclusions: The low intraoperative and postoperative complications rate, observed in the LPS group, highlights the feasibility, safety and efficacy of this surgical approach. The operating time was longer in the LPS group but the recurrence rate and the complication rate appear similar and not more than what is traditionally expected with the LPT approach, although further studies and cost-benefit analyses are required to determine whether the use of LPS improves the outcome over standard LPT and whether the advantages of this technique could be extended to a larger proportion of patients. © 2009 Elsevier Ltd. All rights reserved.

“Administrative data sets are inaccurate for assessing functional outcomes after radical prostatectomy.”
Tollefson, M. K., M. T. Gettman, et al. (2011).
Journal of Urology 185(5): 1686-1690.

Purpose: A recent report examined rates of urinary incontinence and erectile dysfunction following radical prostatectomy by evaluating administrative claims data. However, the validity of this approach for reporting functional outcomes has not been established. Therefore, we determined the prognostic value of administrative claims data for reporting urinary incontinence and erectile dysfunction after radical prostatectomy. Materials and Methods: We identified 562 patients who underwent radical prostatectomy from 2004 to 2007 and were followed at our institution with self-reported standardized survey data available at least 1 year after surgery. Urinary incontinence was assessed by self-reported pad use and the urinary function domain of the Expanded Prostate Cancer Index. Erectile dysfunction was assessed with the International Index of Erectile Function. These results were then compared with administrative claims data using ICD-9 and Hospital International Classification of Diseases Adapted codes for urinary incontinence and erectile dysfunction. Results: Administrative claims data demonstrated a poor correlation with patient self-reported questionnaire data. The administrative identification of erectile dysfunction was associated with a sensitivity of 0.598 and a specificity of 0.591. Poor correlation was also illustrated by the low kappa correlation coefficient of 0.184. Similarly urinary incontinence was poorly correlated with self-reported pad use and the urinary function domain of the Expanded Prostate Cancer Index (correlation coefficient 0.195). Conclusions: Administrative claims data correlate poorly with validated questionnaire data when assessing functional outcomes after radical prostatectomy such as urinary incontinence and erectile dysfunction. Therefore, outcomes data generated using this approach may not reflect the development or severity of such complications. © 2011 American Urological Association Education and Research, Inc.

“Impact of surgical experience on in-hospital complication rates in patients undergoing minimally invasive prostatectomy: A population-based study.”
Budäus, L., M. Sun, et al. (2011).
Annals of Surgical Oncology 18(3): 839-847.

Background. The relationship between provider volume and complication and transfusion rates in patients undergoing minimally invasive prostatectomy (MIRP) for prostate cancer has not been assessed. Temporal trends in MIRP annual surgical caseload (AC), impact of MIRP surgical experience (SE), and in-hospital complication and transfusion rates were evaluated. Methods. Between 2002 and 2008, 2,666 patients in Florida underwent MIRP. Surgical experience was defined as the number of procedures performed from the beginning of the study until each individual MIRP. Multivariable logistic regression models using generalized estimating equations assessed the relationship between SE and inhospital complication and transfusion rates. Results. Overall AC and SE ranged from 1-171 and 1-500, respectively. Between 2002 and 2005, 94-100% of surgeons were considered as low AC tertile (≤15 MIRP) vs. 76-82% between 2006 and 2008. For the same time periods, low AC tertile surgeons performed 46-100 and 27-32% of all MIRPs respectively. Multivariable logistic regression models revealed 51 and 68% lower complication rates in patients operated on by surgeons of intermediate (17-76 MIRPs) and high SE (≥77 MIRPs) relative to surgeons of low SE (≤16 MIRPs). Similarly, transfusion rates were 80 and 83% lower for the same groups. Conclusions. Our study is the first to indicate that high SE reduces MIRP complication and transfusion rates. Despite this observation, even in the most contemporary study year, most MIRP surgeons (82%) were in the low AC tertile and contributed to as many as 32% of all MIRPs. These findings should be considered at informed consent. © Society of Surgical Oncology 2010.

“Minimally invasive versus conventional open mitral valve surgery: A meta-analysis and systematic review.”
Cheng, D. C. H., J. Martin, et al. (2011).
Innovations: Technology and Techniques in Cardiothoracic and Vascular Surgery 6(2): 84-103.

Objective: This meta-analysis sought to determine whether minimally invasive mitral valve surgery (mini-MVS) improves clinical outcomes and resource utilization compared with conventional open mitral valve surgery (conv-MVS) in patients undergoing mitral valve repair or replacement. Methods: A comprehensive search of MEDLINE, Cochrane Library, EMBASE, CTSnet, and databases of abstracts was undertaken to identify all randomized and nonrandomized studies up to March 2010 of mini-MVS through thoracotomy versus conv-MVS through median sternotomy for mitral valve repair or replacement. Outcomes of interest included death, stroke, myocardial infarction, aortic dissection, need for reintervention, and any other reported clinically relevant outcomes or indicator of resource utilization. Relative risk and weighted mean differences and their 95% confidence intervals were analyzed as appropriate using the random effects model. Heterogeneity was measured using the I statistic. Results: Thirty-five studies met the inclusion criteria (two randomized controlled trials and 33 nonrandomized studies). The mortality rate after mini-MVS versus conv-MVS was similar at 30 days (1.2% vs 1.5%), 1 year (0.9% vs 1.3%), 3 years (0.5% vs 0.5%), and 9 years (0% vs 3.7%). A number of clinical outcomes were significantly improved with mini-MVS versus conv-MVS including atrial fibrillation (18% vs 22%), chest tube drainage (578 vs 871 mL), transfusions, sternal infection (0.04% vs 0.27%), time to return to normal activity, and patient scar satisfaction. However, the 30-day risk of stroke (2.1% vs 1.2%), aortic dissection/injury (0.2% vs 0%), groin infection (2% vs 0%), and phrenic nerve palsy (3% vs 0%) were significantly increased for mini-MVS versus conv-MVS. Other clinical outcomes were similar between groups. Cross-clamp time, cardiopulmonary bypass time, and procedure time were significantly increased with mini-MVS; however, ventilation time and length of stay in intensive care unit and hospital were reduced. Conclusions: Current evidence suggests that mini-MVS maybe associated with decreased bleeding, blood product transfusion, atrial fibrillation, sternal wound infection, scar dissatisfaction, ventilation time, intensive care unit stay, hospital length of stay, and reduced time to return to normal activity, without detected adverse impact on long-term need for valvular reintervention and survival beyond 1 year. However, these potential benefits for mini-MVS may come with an increased risk of stroke, aortic dissection or aortic injury, phrenic nerve palsy, groin infections/ complications, and increased cross-clamp, cardiopulmonary bypass, and procedure time. Available evidence is largely limited to retrospective comparisons of small cohorts comparing mini-MVS versus conv-MVS that provide only short-term outcomes. Given these limitations, randomized controlled trials with adequate power and duration of follow-up to measure clinically relevant outcomes are recommended to determine the balance of benefits and risks. Copyright © 2011 by the International Society for Minimally Invasive Cardiothoracic Surgery.

“Robotic surgery. A present and future technological advance.”
Diaz Pavon, J. M. and F. de la Portilla de Juan (2011).
Cir Esp.

“Robotic invasion of operation theatre and associated anaesthetic issues: A review.”
Kakar, P. N., J. Das, et al. (2011).
Indian Journal of Anaesthesia 55(1): 18-25.

A Robotic device is a powered, computer controlled manipulator with artificial sensing that can be reprogrammed to move and position tools to carry out a wide range of tasks. Robots and Telemanipulators were first developed by the National Aeronautics and Space Administration (NASA) for use in space exploration. Today’s medical robotic systems were the brainchild of the United States Department of Defence’s desire to decrease war casualties with the development of ‘telerobotic surgery’. The ‘master-slave’ telemanipulator concept was developed for medical use in the early 1990s where the surgeon’s (master) manual movements were transmitted to end-effector (slave) instruments at a remote site. Since then, the field of surgical robotics has undergone massive transformation and the future is even brighter. As expected, any new technique brings with it risks and the possibility of technical difficulties. The person who bears the brunt of complications or benefit from a new invention is the ‘Patient’. Anaesthesiologists as always must do their part to be the patient’s ‘best man’ in the perioperative period. We should be prepared for screening and selection of patients in a different perspective keeping in mind the steep learning curves of surgeons, long surgical hours, extreme patient positioning and other previously unknown anaesthetic challenges brought about by the surgical robot. In this article we have tried to track the development of surgical robots and consider the unique anaesthetic issues related to robot assisted surgeries.

“From Air Insufflation to Robotic Endoscopic Surgery: A Rocky Road.”
Mettler, L. (2011).
Journal of Minimally Invasive Gynecology 18(3): 275-283.

“Robotic versus laparoscopic surgery: perspectives for tailoring an optimal surgical option.”
Nikiteas, N., D. Roukos, et al. (2011).
Expert Review of Medical Devices 8(3): 295-298.

“From Healing to Witchcraft: On Ritual Speech and Roboticization in the Hospital.”
Pine, A. (2011).
Culture, Medicine and Psychiatry.

Healthcare Information Technology (HIT), touted as a panacea by U.S. political actors ranging from Newt Gingrich to Barack Obama, is central to emerging forms of healthcare governance which Holmes et al.-in their critique of the institutionalization of magical thinking brought about by Orwellian techno-Newspeak-have provocatively labeled fascistic. Drawing from data collected over 3 years of working with and teaching continuing education (CE) courses for thousands of registered nurses as lead political educator for the California Nurses Association/National Nurses Organizing Committee (CNA/NNOC), I argue that HIT is an integral component of a broader technological restructuring of healthcare and thus society, both of which are part of a social discourse that is tied to a transformative system of ritual speech, with profound implications for healthcare work, patient health, and democracy.

“MIS training in Canada: a national survey of general surgery residents.”
Qureshi, A., A. Vergis, et al. (2011).
Surgical Endoscopy: 1-9.

Background: General surgery trainees’ perceptions regarding their own laparoscopic training remain poorly defined. The objective of this survey was to identify and evaluate learner experiences with laparoscopic procedures in general surgery programs on a national level. Methods: Two hundred eighty-four residents were identified and contacted at English-speaking general surgery programs across Canada. Each was asked to complete a web- or paper-based survey regarding their demographics, experiences with basic and advanced minimally invasive surgery (MIS) procedures, and perceived barriers to training. Results: Two hundred fifty-two of 284 (89%) surveyed residents responded. Eighty-seven percent of the residents had access to a skills lab that taught MIS techniques; however, standardized MIS curricula were implemented 53% of the time. Eighty percent of residents felt that skills lab training translated to improved performance in the OR. Although 90% of residents felt that they would be comfortable performing basic laparoscopic procedures, only 8% stated they would be comfortable performing advanced procedures at the end of their training. Moreover, 90% of general surgery residents felt that it was the academic surgical department’s responsibility to teach both basic and advanced procedures, and 35% of respondents felt their surgical program was meeting this requirement. Half of the residents felt they had limited opportunity to be a primary surgeon because an MIS fellow was present. Conclusions: There exists a wide disparity between the expectations of residents and their actual experience. The majority of residents are concerned that they will not acquire sufficient laparoscopic skills during their training to perform advanced cases in practice. Additionally, the balance between resident and fellow-level cases needs to be more clearly defined as the majority of respondents identified the presence of a MIS fellow as a negative learning influence. Finally, although most centers had a surgical skills lab, 47% of respondents felt that the curriculum was not standardized and this also needs to be addressed. © 2011 Springer Science+Business Media, LLC.

“Keeping up with technology.”
Stanton, C. (2011).
AORN Journal 93(1): C1, C8-9.

“How can we ensure lifelong learning for urological specialists?”
Ahmed, K., B. Challacombe, et al. (2011).
BJU International 107(8): 1187-1188.

“Training with simulation versus operative room attendance.”
Desender, L. M., I. Van Herzeele, et al. (2011).
Journal of Cardiovascular Surgery 52(1): 17-37.

Reduced training times, increasing complexity of endovascular and open vascular interventions and concerns for patient’s safety have necessitated a modernisation in surgical training. A more strategic approach is required to facilitate the acquisition of surgical skills outside the operating room and to minimize the risks to patients as surgeons develop their technical expertise. Virtual reality simulation has been proposed as a means to train and objectively assess technical endovascular performance without risks to patient safety. This article reviews the evidence and the limitations for this adjunctive tool, the implementation in current training programmes and future applications to maintain the highest standards of care for treatment of vascular disease.

“Using simulation to train oncology surgeons: gynecologic oncologists practice OR’s touch, feel–and pressures.”
Glickson, J. (2011).
Bulletin of the American College of Surgeons 96(3): 31-38.

“Lessons learned: End-user assessment of a skills laboratory based training programme for urology trainees.”
Grills, R., N. Lawrentschuk, et al. (2011).
BJU International 107(SUPPL. 3): 47-51.


  • To evaluate the benefit of a skills laboratory based training programme to urology resident training by end-user assessment. SUBJECTS AND METHODS All participants in a urological skills workshop programme conducted at the Royal Australasian College of Surgeons in Melbourne, Australia, between 2004 and 2009 were included. This was a retrospective review using a structured questionnaire. Topics regarding course organization, content, delivery and relevance to clinical practice were examined. Free-text entry responses allowed participants to elaborate on specific points as appropriate. RESULTS During the study period, 35 individual workshops were conducted. In all, 41 of 43 eligible participants completed the survey for a response rate of 95%. Overall, 26 (63%) found the experience valuable, interesting and useful. Of the remainder (37%), four (10%) found it interesting but not useful to training, five (12%) found it useful and a good idea but not well conducted, and two (5%) found it neither interesting nor useful for training. Workshop success was intimately related to the quality of the simulator or model used: highly rated workshops consistently used models that were ‘realistic’ and ‘life-like’, while poorly rated workshops were associated with models considered ‘impossible’ and ‘not tested’. CONCLUSIONS The use of skills laboratory based workshops can enhance the surgical training of urology residents, at least as assessed by the end-users themselves. However, closer attention to the selection and use of properly tested and validated models may maximize the educational opportunity. Translational research prospectively examining the impact of workshops on live patient surgery and outcomes is still required. © 2011 BJU INTERNATIONAL.

“Single-incision laparoscopic surgery (SILSTM) versus standard laparoscopic surgery: A comparison of performance using a surgical simulator.”
Santos, B. F., D. Enter, et al. (2011).
Surgical Endoscopy and Other Interventional Techniques 25(2): 483-490.

Background Single-incision laparoscopic surgery (SILSTM) is a potentially less invasive approach than standard laparoscopy (LAP). However, SILSTM may not allow the same level of manual dexterity and technical performance compared to LAP. We compared the performance of standardized tasks from the Fundamentals of Laparoscopic Surgery (FLS) program using either the LAP or the SILSTM technique. Methods Medical students, surgical residents, and attending physicians were recruited and divided into inexperienced (IE), laparoscopy-experienced (LE), and SILSTM-experienced (SE) groups. Each subject performed standardized tasks from FLS, including peg transfer, pattern cutting, placement of ligating loop, and intracorporeal suturing using a standard three-port FLS box-trainer with standard laparoscopic instruments. For SILSTM the subjects used an FLS box-trainer modified to accept a SILS PortTM with two working ports for instruments and one port for a 30° 5-mm laparoscope. SILSTM tasks were performed with instruments capable of unilateral articulation. SILSTM suturing was performed both with and without an articulating EndoStitchTM device. Task scores, including cumulative laparoscopic FLS score (LS) and cumulative SILSTM FLS score (SS), were calculated using standard time and accuracy metrics. Results There were 27 participants in the study. SS was inferior to LS in all groups. LS increased with experience level, but was similar between LE and SE groups. SS increased with experience level and was different among all groups. SILSTM suturing using the articulating suturing device was superior to the use of a modified needle driver technique. Conclusions SILSTM is more technically challenging than standard laparoscopic surgery. Using currently available SILSTMplatforms and instruments, even surgeons with SILSTM experience are unable to match their overall LAP performance. Specialized training curricula should be developed for inexperienced surgeons who wish to perform SILSTM. © Springer Science+Business Media, LLC 2010.

“No surgeon should operate alone: How telementoring could change operations.”
Wood, D. (2011).
Telemedicine and e-Health 17(3): 150-152.

“Surgeon’s vigilance in the operating room.”
Zheng, B., G. Tien, et al. (2011).
American Journal of Surgery 201(5): 667-671.

Objective: Surgeons’ vigilance regarding patient condition was assessed using eye-tracking techniques during a simulated laparoscopic procedure. Methods: Surgeons were required to perform a partial cholecystectomy in a virtual reality trainer (SurgicalSim; METI Inc, Sarasota, FL) while wearing a lightweight head-mounted eye-tracker (Locarna systems Inc, Victoria, British Columbia, Canada). Half of the patients were preprogrammed to present a mildly unstable cardiac condition during the procedure. Surgical performance (evaluated by task time, instrument trajectory, and errors), mental workload (by the National Aeronautics and Space Administration Task Load Index), and eye movement were recorded and compared between 13 experienced and 10 novice surgeons. Results: Experienced surgeons took longer to complete the task and also made more errors. The overall workload reported by surgeons was similar, but expert surgeons reported a higher level of frustration and a lower level of physical demands. Surgeon workload was greater when operating on the unstable patient than on the stable patient. Novices performed faster but focused more of their attention on the surgical task. In contrast, experts glanced more frequently at the anesthetic monitor. Conclusions: This study shows the usefulness of using eye-tracking technology to measure a surgeon’s vigilance during an operation. Eye-tracking observations can lead to inferences about a surgeon’s behavior for patient safety. The unsatisfactory performance of expert surgeons on the VR simulator suggests that the fidelity of the virtual simulator needs to improve to enable surgeons to transfer their clinical skills. This, in turn, suggests using caution when having clinical experts as instructors to teach skills with virtual simulators. © 2011 Elsevier Inc. All rights reserved.