“Annual surgical caseload and open radical prostatectomy outcomes: Improving temporal trends.”
Budäus, L., F. Abdollah, et al. (2010).
Journal of Urology184(6): 2285-2290.
Purpose Radical prostatectomy is the standard of care for localized prostate cancer. Numerous previous reports show the relationship between surgical experience and various outcomes. We examined the effect of surgical experience on complications and transfusion rates, and determined individual surgeon annual caseload trends in a contemporary radical prostatectomy cohort. Materials and Methods We analyzed annual caseload temporal trends in 34,803 patients who underwent surgery between 1999 and 2008 in Florida. Logistic regression models controlled for clustering among surgeons addressed the relationship of surgical experience, defined as the number of radical prostatectomies done since January 1, 1999 until each radical prostatectomy, with complications and transfusions. Results During the study period the proportion of surgeons in the high annual caseload tertile (24 radical prostatectomies or greater yearly) and the proportion of patients treated by those surgeons increased from 5% to 10% and from 20% to 55%, respectively. Conversely complication and transfusion rates decreased from 14.3% to 9.2% and 12.6% to 6.9%, respectively. Radical prostatectomies done by surgeons in the high surgical experience tertile (86 or greater radical prostatectomies) decreased the risk of any complication by 33% and of any transfusion by 30% vs those in patients operated on by surgeons in the low surgical experience tertile (27 or fewer radical prostatectomies). Conclusions The proportion of surgeons in the high annual caseload tertile and the proportion of patients treated by these surgeons steadily increased during the last decade. Complication and transfusion rates decreased with time. The implications of these encouraging findings may result in improved outcomes in patients with surgically managed prostate cancer. © 2010 American Urological Association Education and Research, Inc.
“Five year biochemical recurrence free survival for intermediate risk prostate cancer after radical prostatectomy, external beam radiation therapy or permanent seed implantation.”
Vassil, A. D., E. S. Murphy, et al. (2010).
Objective: To compare biochemical recurrence-free survival (bRFS) for patients with intermediate-risk prostate cancer treated by retropubic radical prostatectomy (RRP), laparoscopic radical prostatectomy (LRP), external beam radiation therapy (RT), or permanent seed implantation (PI). Methods: Patients treated for intermediate-risk prostate cancer per National Comprehensive Cancer Network guidelines from 1996 to 2005 were studied. Variables potentially affecting bRFS were examined using univariate and multivariate Cox regression analysis. Five-year bRFS rates were calculated by actuarial methods; bRFS was calculated using Kaplan-Meier analysis. Nadir +2 definition of biochemical failure was used for RT and PI patients; a PSA <0.4 ng/mL was used for radical prostatectomy (RP) patients. Time to initiation of salvage therapy was compared for each treatment group using the Kruskal-Wallis test. Results: Nine-hundred seventy-nine patients were analyzed with a median follow-up of 65 months. Five years bRFS rate was 82.8% for all patients (89.5% PI, 85.7% RT, 79.9% RRP, and 60.2% LRP). Patients treated by LRP had significantly worse bRFS than RT (P < .0001), PI (P < .0001), or RRP patients (P = .0038). Treatment modality (P < .0001) and average number of PSA tests per year (P < .0001) were the only independent predictors of bRFS on multivariate analysis. Median time to initiation of salvage therapy from time of treatment was 28.6 months for all patients (26.1 RP, 21.0 LRP, 47.4 PI, 47.8 RT; P < .0001). Conclusions: Patients with intermediate-risk prostate cancer choosing PI, RT, or RRP appear to have improved 5-year bRFS and delayed salvage therapy compared with LRP. © 2010 Elsevier Inc. All Rights Reserved.
“Systematic review of the efficacy and safety of high-intensity focussed ultrasound for the primary and salvage treatment of prostate cancer.”
Warmuth, M., T. Johansson, et al. (2010).
European Urology58(6): 803-815.
Context: High-intensity focussed ultrasound (HIFU) is an emerging minimally invasive treatment option for prostate cancer. Objective: Our aim was to assess the efficacy and safety of HIFU in both primary treatment of men with localised and locally advanced prostate cancer as well as salvage treatment of men with recurrent prostate cancer following treatment failure of radical prostatectomy or external-beam radiation therapy. Evidence acquisition: We conducted a systematic literature search for studies conducted on humans and published in either English or German in several databases from 2000 to 2010. In addition, we screened several Web sites for assessments on HIFU in prostate cancer and contacted the manufacturers of the two currently available HIFU devices for supplemental information on HIFU. We included all prospective studies with >50 study participants and assessed their quality using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. Evidence synthesis: We identified 20 uncontrolled prospective case series, each of which treated between 58 and 517 patients. These studies were all conducted within the past decade. In total, 3018 patients were treated with HIFU, 93% for primary therapy and 7% for salvage HIFU. For all HIFU procedures, the biochemical disease-free survival rate at 1, 5, and 7 yr, respectively, was 78-84%, 45-84%, and 69%. The negative biopsy rate was 86% at 3 mo and 80% at 15 mo. Overall survival rates and prostate cancer-specific survival rates were 90% and 100% at 5 yr and 83% and 98% at 8 yr, respectively. Adverse events concerned the urinary tract (1-58%), potency (1-77%), the rectum (0-15%), and pain (1-6%). Quality-of-life assessment yielded controversial results. Conclusions: Applying the GRADE approach, the available evidence on efficacy and safety of HIFU in prostate cancer is of very low quality, mainly due to study designs that lack control groups. More research is needed to explore the use of HIFU in prostate cancer. © 2010 European Association of Urology.
“Robotic surgery and anesthesia.”
Quesnez, J. (2010).
Anesthésie et chirurgie robotisée23(112): 9-11.
“Robotic telemanipulating surgical systems for laparoscopy: the story so far in the UK.”
Sood, H. S., M. Arya, et al. (2010).
Expert Review of Medical Devices7(6): 745-752.
Surgical robotics is, at present, one of the most dynamically developing areas of biomedical engineering that has been proven to increase the stability and robustness of surgery. Robotics can integrate, assist, control and extend the human capabilities, correcting for manual errors, or record the spatial points-of-interest and motions. This is of importance as an adjunct to many laparoscopic subspecialty procedures, from cardiac to pelvic surgery. Evidence-based medicine is now demonstrating that robotized equipment can greatly add to the preoperative simulation, the ergonomics of the procedure, the preoperative simulation and the risk-free training of the surgeon with precision surgery and less trauma to the patient. This article discusses the robots that are clinically available at present and their importance to the surgeon and patient.
“Real-time stereo reconstruction in robotically assisted minimally invasive surgery.”
Stoyanov, D., M. V. Scarzanella, et al. (2010).
Medical image computing and computer-assisted intervention : MICCAI … International Conference on Medical Image Computing and Computer-Assisted Intervention13(Pt 1): 275-282.
The recovery of 3D tissue structure and morphology during robotic assisted surgery is an important step towards accurate deployment of surgical guidance and control techniques in minimally invasive therapies. In this article, we present a novel stereo reconstruction algorithm that propagates disparity information around a set of candidate feature matches. This has the advantage of avoiding problems with specular highlights, occlusions from instruments and view dependent illumination bias. Furthermore, the algorithm can be used with any feature matching strategy allowing the propagation of depth in very disparate views. Validation is provided for a phantom model with known geometry and this data is available online in order to establish a structured validation scheme in the field. The practical value of the proposed method is further demonstrated by reconstructions on various in vivo images of robotic assisted procedures, which are also available to the community.
“Juvenile nasopharyngeal angiofibroma: Current treatment modalities and future considerations.”
Hodges, J. M., A. S. McDevitt, et al. (2010).
Indian Journal of Otolaryngology and Head and Neck Surgery62(3): 236-247.
Juvenile angiofibroma (JNA) is a relatively uncommon, highly vascular and benign tumor that presents most commonly in adolescent males. Symptoms may persist from months to years and often times, these tumors are asymptomatic until they increase and encroach on critical structures. Because of technological advances both in surgery and radiology, management of JNA patients has been refined. With the advent of more sophisticated capabilities such as CT, MRI, intensity-modulated radiation therapy (IMRT), stereotactic guidance systems as well as advanced embolization techniques, these tumors can be diagnosed and managed more effectively. Patients with juvenile angiofibroma (JNA) are typically silent for years and often present with epistaxis, nasal obstruction, facial numbness, rhinorrhea, ear popping, sinusitis, cheek swelling, visual changes and headaches. In addition to these symptoms, up to one-third of patients with this condition may present with proptosis or other orbital involvement, which are late symptoms and findings. Most physicians agree that surgery is the primary treatment modality for the early-stage disease process. However, controversy arises regarding the best treatment when a patient presents with more locally advanced disease involving widespread cranial-based extension or intracranial involvement which may necessitate a combination of treatment modalities including surgery and postoperative radiation. With the advancement of endoscopic surgery, there have been a number of cases reporting the value of its use. The purpose of this review, however, will address not only endoscopic alternatives, but will discuss other treatment options as reported in the literature. Robotic surgery of the skull base for JNA is something to expect for the future. Finally, with the advent of IMRT and an image-guided robotic radiotherapy delivery system, some researchers speculate that this will result in less objections for radiation in general and certainly less reservations for the use radiotherapy in certain circumstances, i. e. patient refusal of surgery or extensive non-resectable or recurrent JNA tumors. © 2010 Association of Otolaryngologists of India.
Novotny, T., M. Dvorak, et al. (2010).
Journal of Vascular Surgery.
BACKGROUND:: Since the end of the 20th century, robot-assisted surgery has been finding its role among other minimally invasive methods. Vascular surgery seems to be another specialty in which the benefits of this technology can be expected. Our objective was to assess the learning curve of robot-assisted laparoscopic aortofemoral bypass grafting for aortoiliac occlusive disease in a group of 40 patients. METHODS:: Between May 2006 and January 2010, 40 patients (32 men, 8 women), who were a median age of 58 years (range, 48-75 years), underwent 40 robot-assisted laparoscopic aortofemoral reconstructions. Learning curve estimations were used for anastomosis, clamping, and operative time assessment. For conversion rate evaluation, the cumulative summation (CUSUM) technique was used. Statistical analysis comparing the first and second half of our group, and unilateral-to-bilateral reconstructions were performed. RESULTS:: We created 21 aortofemoral and 19 aortobifemoral bypasses. The median proximal anastomosis time was 23 minutes (range, 18-50 minutes), median clamping time was 60 minutes (range, 40-95 minutes), and median operative time was 295 minutes (range, 180-475 minutes). The 30-day mortality rate was 0%, and no graft or wound infection or cardiopulmonary or hepatorenal complications were observed. During the median 18-month follow-up (range, 2-48 months), three early graft occlusions occurred (7%). After reoperations, the secondary patency of reconstructions was 100%. Data showed a typical short learning curve for robotic proximal anastomosis creation with anastomosis and clamping time reduction. The operative time learning curve was flat, confirming the procedure’s complexity. There were two conversions to open surgery. CUSUM analysis confirmed that an acceptable conversion rate set at 5% was achieved. Comparing the first and second half of our group, all recorded times showed statistically significant improvements. Differences between unilateral and bilateral reconstructions were not statistically significant. CONCLUSIONS:: Our results show that the success rate of robot-assisted laparoscopic aortofemoral bypass grafting is high and the complication rate is low. Anastomosis creation, one of the main difficulties of laparoscopic bypass grafting, has been overcome using the robotic operating system and its learning curve is short. However, the endoscopic dissection of the aortoiliac segment remains the most difficult part of the operation and should be addressed in further development of the method to reduce the operative times. Long-term results and potential benefits of this minimally invasive method have to be verified by randomized controlled clinical trials.