“Current status of robotic assisted pelvic surgery and future developments.”
Ahmed, K., M. S. Khan, et al. (2009).
Int J Surg.
AIMS: The aim of this review is to assess the role of robotics in pelvic surgery in terms of outcomes. We have also highlighted the issues related to training and future development of robotic systems. MATERIALS AND METHODS: We searched MEDLINE, EMBASE and the Cochrane Databases from 1980 to 2009 for systematic reviews of randomised controlled trials, prospective observational studies, retrospective studies and case reports assessing robotic surgery. RESULTS: During the last decade, there has been a tremendous rise in the use of robotic surgical systems for all forms of precision operations including pelvic surgery. The short-term results of robotic pelvic surgery in the fields of urology, colorectal surgery and gynaecology have been shown to be comparable to the laparoscopic and open surgery. Robotic surgery offers an opportunity where many of these obstacles encountered during open and laparoscopic surgery can be overcome. CONCLUSIONS: Robotic surgery is a continually advancing technology, which has opened new horizons for performing pelvic surgery with precision and accuracy. Although its use is rapidly expanding in all surgical disciplines, particularly in pelvic surgery, further comparative studies are needed to provide robust guidance about the most appropriate application of this technology within the surgical armamentarium.
“Video-games station or minimally invasive skills training station?”
Alnajjar, H. M. and J. Virdi (2009).
BJU International 104(7): 1020.
“Robotic laparoscopic surgery: Cost and training.”
Amodeo, A., A. Linares Quevedo, et al. (2009).
Minerva Urologica e Nefrologica 61(2): 121-128.
The advantages of minimally invasive surgery are well accepted. Shorter hospital stays, decreased postoperative pain, rapid return to preoperative activity, decreased postoperative ileus, and preserved immune function are among the benefits of the laparoscopic approach. However, the instruments of laparoscopy afford surgeons limited precision and poor ergonomics, and their use is associated with a significant learning curve and the amount of time and energy necessary to develop and maintain such advanced laparoscopic skills is not insignificant. The robotic surgery allows all laparoscopists to perform advanced laparoscopic procedures with greater ease. The potential advantages of surgical robotic systems include making advanced laparoscopic surgical procedures accessible to surgeons who do not have advanced video endoscopic training and broadening the scope of surgical procedures that can be performed using the laparoscopic method. The wristed instruments, x10 magnifications, tremor filtering, scaling of movements and three-dimensional view allow the urologist to perform the intricate dissection and anastomosis with high precision. The robot is not, however, without significant disadvantages as compared with traditional laparoscopy. These include greater expense and consumption of operating room resources such as space and the availability of skilled technical staff, complete elimination of tactile feedback, and more limited options for trocar placement. The current cost of the da Vinci system is $ 1.2 million and annual maintenance is $ 138 000. Many studies suggest that depreciation and maintenance costs can be minimised if the number of robotic cases is increased. The high cost of purchasing and maintaining the instruments of the robotic system is one of its many disadvantages. The availability of the robotic systems to only a limited number of centres reduces surgical training opportunities. Hospital administrators and surgeons must define the reasons for developing a robotic surgical program: it is very important to show that robotics will add a dimension that will benefit the hospital, the patient care and institutional recognition. Another essential task to overcome is the important education of the operating room nursing staff, a significant difference between this modality and traditional surgery. Without operating room environment support, most surgeons will revert to traditional methods even after a few successful robotics cases. As the field of robotic surgery continues to grow, graduate medical education and continuing medical education programs that address the surgical robotic learning needs of residents and practicing surgeons need to be developed.
“Rise of the machines.”
Basu, I. (2009).
International Journal of Surgery 7(4): 399-400.
“Bringing Da Vinci to dentistry.”
Bonett, J. B. (2009).
The Penn dental journal 5(2): 2-5.
“The clavien-dindo classification of surgical complications: Five-year experience.”
Clavien, P. A., J. Barkun, et al. (2009).
Annals of Surgery 250(2): 187-196.
Background and Aims: The lack of consensus on how to define and grade adverse postoperative events has greatly hampered the evaluation of surgical procedures. A new classification of complications, initiated in 1992, was updated 5 years ago. It is based on the type of therapy needed to correct the complication. The principle of the classification was to be simple, reproducible, flexible, and applicable irrespective of the cultural background. The aim of the current study was to critically evaluate this classification from the perspective of its use in the literature, by assessing interobserver variability in grading complex complication scenarios and to correlate the classification grades with patients’, nurses’, and doctors’ perception. Material and Methods: Reports from the literature using the classification system were systematically analyzed. Next, 11 scenarios illustrating difficult cases were prepared to develop a consensus on how to rank the various complications. Third, 7 centers from different continents, having routinely used the classification, independently assessed the 11 scenarios. An agreement analysis was performed to test the accuracy and reliability of the classification. Finally, the perception of the severity was tested in patients, nurses, and physicians by presenting 30 scenarios, each illustrating a specific grade of complication. Results: We noted a dramatic increase in the use of the classification in many fields of surgery. About half of the studies used the contracted form, whereas the rest used the full range of grading. Two-thirds of the publications avoided subjective terms such as minor or major complications. The study of 11 difficult cases among various centers revealed a high degree of agreement in identifying and ranking complications (89% agreement), and enabled a better definition of unclear situations. Each grade of complications significantly correlated with the perception by patients, nurses, and physicians (P < 0.05, Kruskal-Wallis test). Conclusions: This 5-year evaluation provides strong evidence that the classification is valid and applicable worldwide in many fields of surgery. No modification in the general principle of classification is warranted in view of the use in ongoing publications and trials. Subjective, inaccurate, or confusing terms such as “minor or major” should be removed from the surgical literature. © 2009 Lippincott Williams & Wilkins, Inc.
“Impact of IQ, computer-gaming skills, general dexterity, and laparoscopic experience on performance with the da Vinci surgical system.”
Hagen, M. E., O. J. Wagner, et al. (2009).
Int J Med Robot 5(3): 327-331.
BACKGROUND: Due to improved ergonomics and dexterity, robotic surgery is promoted as being easily performed by surgeons with no special skills necessary. We tested this hypothesis by measuring IQ elements, computer gaming skills, general dexterity with chopsticks, and evaluating laparoscopic experience in correlation to performance ability with the da Vinci robot. METHODS: Thirty-four individuals were tested for robotic dexterity, IQ elements, computer-gaming skills and general dexterity. Eighteen surgically inexperienced and 16 laparoscopically trained surgeons were included. Each individual performed three different tasks with the da Vinci surgical system and their times were recorded. An IQ test (elements: logical thinking, 3D imagination and technical understanding) was completed by each participant. Computer skills were tested with a simple computer game (hand-eye coordination) and general dexterity was evaluated by the ability to use chopsticks. RESULTS: We found no correlation between logical thinking, 3D imagination and robotic skills. Both computer gaming and general dexterity showed a slight but non-significant improvement in performance with the da Vinci robot (p > 0.05). A significant correlation between robotic skills, technical understanding and laparoscopic experience was observed (p < 0.05). CONCLUSIONS: The data support the conclusion that there are no significant correlations between robotic performance and logical thinking, 3D understanding, computer gaming skills and general dexterity. A correlation between robotic skills and technical understanding may exist. Laparoscopic experience seems to be the strongest predictor of performance with the da Vinci surgical system. Generally, it appears difficult to determine non-surgical predictors for robotic surgery.
“Simulation modeling for the health care manager.”
Kennedy, M. H. (2009).
Health Care Manager 28(3): 246-252.
This article addresses the use of simulation software to solve administrative problems faced by health care managers. Spreadsheet add-ins, process simulation software, and discrete event simulation software are available at a range of costs and complexity. All use the Monte Carlo method to realistically integrate probability distributions into models of the health care environment. Problems typically addressed by health care simulation modeling are facility planning, resource allocation, staffing, patient flow and wait time, routing and transportation, supply chain management, and process improvement. © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins.
“The future of robotics in hand surgery.”
Liverneaux, P., E. Nectoux, et al. (2009).
Chirurgie de la Main.
Robotics has spread over many surgical fields over the last decade: orthopaedic, cardiovascular, urologic, gynaecologic surgery and various other types of surgery. There are five different types of robots: passive, semiactive and active robots, telemanipulators and simulators. Hand surgery is at a crossroad between orthopaedic surgery, plastic surgery and microsurgery; it has to deal with fixing all sorts of tissues from bone to soft tissues. To our knowledge, there is not any paper focusing on potential clinical applications in this realm, even though robotics could be helpful for hand surgery. One must point out the numerous works on bone tissue with regard to passive robots (such as fluoroscopic navigation as an ancillary for percutaneous screwing in the scaphoid bone). Telemanipulators, especially in microsurgery, can improve surgical motion by suppressing physiological tremor thanks to movement demultiplication (experimental vascular and nervous sutures previously published). To date, the robotic technology has not yet become simple-to-use, cheap and flawless but in the future, it will probably be of great technical help, and even allow remote-controlled surgery overseas. © 2009 Elsevier Masson SAS. All rights reserved.
“Robotic and laparoscopic surgery: cost and training.”
Patel, H. R., A. Linares, et al. (2009).
Surg Oncol 18(3): 242-246.
Robotic prostatectomy training as part of mainstream surgical training will be difficult. The primary problems revolve around the inconsistencies of standard sugery. Many surgeons are still in the learning curve, as is the understanding of the true capabilities of the robot. The important elements of robotic surgery actually enhance basic laparoscopic techniques. The prostate has been shown to be an organ where this new technology has a niche. As we move toward cross specialty use the robot although extremely expensive, may be the best way to train the laparoscopic surgeon of the future.
“Training requirements and credentialing for laparoscopic and robotic surgery–what are our responsibilities?”
Schwartz, B. F. (2009).
J Urol 182(3): 828-829.
“The accordion severity grading system of surgical complications.”
Strasberg, S. M., D. C. Linehan, et al. (2009).
Annals of Surgery 250(2): 177-186.
Background: A severity grading system is essential to reporting surgical complications. In 1992, we presented such a system (T92). Its use and that of systems derived from it have increased exponentially. Our purpose was to determine how well T92 and its modifications have functioned as a severity grading system and to develop an improved system for reporting complications. Methods: 129 articles were studied in detail. Twenty variables were searched for in each article with particular emphasis on type of study, substitution of qualitative terms for grades, grade compression, and cut-points if grade compression was used. We also determined relative distribution of complications and manner of presentation of complications. Results: T92 and derivative classifications have received wide use in surgical studies ranging from small studies with few complications to large studies of complex operations that describe many complications. There is a strong tendency to contract classifications and to substitute terms with self evident meaning for the numerical grades. Complications are presented in a large variety of tabular forms some of which are much easier to follow than others. Conclusions: Current methods for reporting the severity of complications incompletely fulfill the needs of authors of surgical studies. A new system-the Accordion Severity Grading System-is presented. The Accordion system can be used more readily for small as well as large studies. It introduces standard definition of simple quantitative terms and presents a standard tabular reporting system. This system should bring the field closer to a common severity grading method for surgical complications. © 2009 Lippincott Williams & Wilkins, Inc.
“Assessing the Impact of Ischaemia Time During Partial Nephrectomy.”
Becker, F., H. Van Poppel, et al. (2009).
European Urology 56(4): 625-635.
Context: The impact of applying renal ischaemia during nephron-sparing surgery to avoid renal damage in the treated kidney has gained importance in different surgical techniques. Objective: The main objective of the present study is to point out the limit of renal ischaemia times for warm and cold ischaemia approaches. Important results of research on renal ischaemia and different surgical techniques as well as results of clinical studies concerning renal function after renal ischaemia in partial nephrectomy are highlighted. Evidence acquisition: A Medline literature research was performed, combining queries on the keywords nephron-sparing surgery, partial nephrectomy, and ischemia. Links to related articles and cross-reading of citations in related articles were surveyed, as were reviews, letters to editors, and information collected from urologic textbooks. The references formed the basis of this review article, with selection and deletion based on the relevance and importance of the content. In a final step, interactive peer review by the expert panel of coauthors completed the review. Evidence synthesis: Renal ischaemia research showed an increasing renal damage proportional to ischemic time. Current clinical data support safe ischaemia times, within 20 min of warm ischaemia and up to 2 h of cold ischaemia, to minimise renal ischemic damage. To date, no ischaemia dose-response curve or algorithm is available to predict the risk of acute kidney injury and chronic kidney disease in patients undergoing intraoperative ischaemia. In general, there seems to be a higher risk for comorbidity caused by renal damage in patients suffering from kidney tumour. Conclusions: If ischaemia is required, the tumour should be removed within 20 min of warm ischaemia, regardless of surgical approach. Efforts should be made to start immediately with cold ischaemia, if the feasibility within this span of time seems to be jeopardised. Thus, cold ischaemia times up to 2 h can be tolerated by the kidney, depending on the individual method. Nevertheless, cold ischaemia with ice slush should be kept as short as possible-at best within 35 min. In ischemic nephron-sparing surgery, one of the surgeon’s main aims should be to avoid loss of renal function. Only after optimal preoperative appraisal and planning can the best postoperative outcomes for renal function be achieved. © 2009 European Association of Urology.
“Delayed Prostate-specific Antigen Recurrence After Radical Prostatectomy: How to Identify and What Are Their Clinical Outcomes?”
Caire, A. A., L. Sun, et al. (2009).
Urology 74(3): 643-647.
Objectives: To identify factors that predict delayed (> 5 years) prostate-specific antigen recurrence (PSAR) after radical prostatectomy (RP) and to analyze the associated clinical outcomes. Methods: A cohort of 4561 men who underwent RP between 1988 and 2008 was retrieved from the Duke University Prostate Center database. Among them, 1207 (26.5%) had PSAR and were included in this study. The cohort was then divided into 2 groups; PSAR before 5 years (early PSAR) and PSAR after 5 years (delayed PSAR), and Kaplan Meier analysis was performed. Univariate and logistic regression analysis was carried out to determine significant predictors of delayed PSAR, using factors such as race, age, body mass index, PSA, surgical margin status, pathologic Gleason sum, pathologic tumor stage, and prostate weight. Results: There was a marginal difference between the early and delayed PSAR groups with regard to metastasis-free survival (P = .062). A significant difference in disease-specific survival was found between the 2 groups (P = .025). Patients with pathologic Gleason sums < 7 were more likely to have delayed PSAR as compared to those with pathologic Gleason sums > 7 (OR = 2.38). Patients with a PSA < 10 ng/mL were more likely to have delayed PSAR in comparison to those with PSA > 20 ng/mL (OR = 2.38). Conclusions: Approximately 90% of PSAR occurred within 5 years after RP. Lower pathologic Gleason sums and lower PSA at diagnosis were associated with delayed PSAR. Patients with delayed PSAR have a disease-specific survival advantage as compared to men with early PSAR. © 2009 Elsevier Inc. All rights reserved.
“Laparoscopy and gynecologic oncology.”
Cho, J. E., C. Liu, et al. (2009).
Clinical Obstetrics and Gynecology 52(3): 313-326.
Laparoscopy was used for a second-look assessment in ovarian cancer patients back in the 1970s. However, it is only with the advent of new developments in equipment in the late 1980s and early 1990s along with the vision of pioneers in laparoscopic surgery that has made operative laparoscopy in gynecologic oncology feasible. Laparoscopy has multiple benefits in the cancer patients, including image magnification to visualize metastatic or recurrent disease and improved dissection in challenging areas such as the paravesical and pararectal spaces. There is limited bleeding from small vessels because of the pressure from pneumoperitoneum, decreased hospital stay, and rapid recovery. Postoperative chemotherapy or radiation can be initiated earlier, and radiation complications from bowel adhesions are minimized. Significant progress has been made in the last 2 decades in gynecologic malignancy. In this study, the application of laparoscopy in cervical, endometrial, and ovarian cancer will be presented. © 2009 Lippincott Williams & Wilkins, Inc.
“The clavien-dindo classification of surgical complications: Five-year experience.”
Clavien, P. A., J. Barkun, et al. (2009).
Annals of Surgery 250(2): 187-196.
Background and Aims: The lack of consensus on how to define and grade adverse postoperative events has greatly hampered the evaluation of surgical procedures. A new classification of complications, initiated in 1992, was updated 5 years ago. It is based on the type of therapy needed to correct the complication. The principle of the classification was to be simple, reproducible, flexible, and applicable irrespective of the cultural background. The aim of the current study was to critically evaluate this classification from the perspective of its use in the literature, by assessing interobserver variability in grading complex complication scenarios and to correlate the classification grades with patients’, nurses’, and doctors’ perception. Material and Methods: Reports from the literature using the classification system were systematically analyzed. Next, 11 scenarios illustrating difficult cases were prepared to develop a consensus on how to rank the various complications. Third, 7 centers from different continents, having routinely used the classification, independently assessed the 11 scenarios. An agreement analysis was performed to test the accuracy and reliability of the classification. Finally, the perception of the severity was tested in patients, nurses, and physicians by presenting 30 scenarios, each illustrating a specific grade of complication. Results: We noted a dramatic increase in the use of the classification in many fields of surgery. About half of the studies used the contracted form, whereas the rest used the full range of grading. Two-thirds of the publications avoided subjective terms such as minor or major complications. The study of 11 difficult cases among various centers revealed a high degree of agreement in identifying and ranking complications (89% agreement), and enabled a better definition of unclear situations. Each grade of complications significantly correlated with the perception by patients, nurses, and physicians (P < 0.05, Kruskal-Wallis test). Conclusions: This 5-year evaluation provides strong evidence that the classification is valid and applicable worldwide in many fields of surgery. No modification in the general principle of classification is warranted in view of the use in ongoing publications and trials. Subjective, inaccurate, or confusing terms such as “minor or major” should be removed from the surgical literature. © 2009 Lippincott Williams & Wilkins, Inc.
“Novel treatment methods for localized prostate cancer: Hypofractionated robotic radiation therapy and adjuvant hemotherapy.”
Dawson, N. A. and S. P. Collins (2009).
Expert Review of Anticancer Therapy 9(7): 953-962.
The standard localized therapies for prostate cancer include external-beam radiation therapy, brachytherapy and radical prostatectomy. There are several novel approaches in development aimed at improving local disease control and survival, and reducing post-treatment complications. In low-to-intermediate-risk patients, new radiation approaches are being explored to include hypofractionated robotic radiation therapy. For high-risk patients, the focus is on multimodality approaches, especially the addition of chemotherapy. Recent developments in radiation therapy and adjuvant chemotherapy are the focus of this review. © 2009 Expert Reviews Ltd.
“Stereotactic body radiotherapy: an emerging treatment approach for localized prostate cancer.”
Friedland, J. L., D. E. Freeman, et al. (2009).
Technol Cancer Res Treat 8(5): 387-392.
Here we report results from the first cohort of over 100 patients treated with hypofractionated, stereotactic body radiotherapy (SBRT) for early stage prostate cancer. Between February 2005 and December 2006, 112 patients with localized, biopsy-proven adenocarcinoma of the prostate (clinical stage T1cN0M0 to T2cN0M0) were treated in Naples, FL on a CyberKnife system (Accuray Incorporated, Sunnyvale, CA). Eighty-one patients had a Gleason score of 3+3. Mean initial PSA was 6.0, and mean initial prostate volume was 46.3cc. Implanted gold fiducials were used for image-guided targeting and tracking. Patients received 35-36 Gy administered in 5 consecutive fractions to the prostate and the proximal seminal vesicles, as identified on CT and MRI scans. At a median follow-up of 24 months, the mean PSA value was 0.78 ng/ml. Two patients have developed biopsy-confirmed local relapse; one developed distant metastases. Acute side effects were generally mild and resolved shortly after treatment. A single Grade 3 rectal complication was reported (bleeding). Eighty-two percent of patients who were sexually potent before treatment maintained erectile function post-treatment. Additional follow-up is required to better evaluate potential late toxicity and long-term PSA outcomes.
“Simulation modeling for the health care manager.”
Kennedy, M. H. (2009).
Health Care Manager 28(3): 246-252.
This article addresses the use of simulation software to solve administrative problems faced by health care managers. Spreadsheet add-ins, process simulation software, and discrete event simulation software are available at a range of costs and complexity. All use the Monte Carlo method to realistically integrate probability distributions into models of the health care environment. Problems typically addressed by health care simulation modeling are facility planning, resource allocation, staffing, patient flow and wait time, routing and transportation, supply chain management, and process improvement. © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins.
“CyberknifeTM for the treatment of non-metastatic prostate cancer.”
Lee, S. J., K. Song, et al. (2009).
Korean Journal of Urology 50(8): 744-750.
Purpose: The radiobiology of prostate cancer favors a hypofractionated dose regimen. We report here our experience with the CyberKnifeTM, demonstrating its efficacy, safety, and feasibility as a treatment modality for non-metastatic prostate cancer. Materials and Methods: Between October 2002 and April 2006, 20 patients with biopsy-proven prostate cancer were treated with the CyberKnifeTM. The distribution of clinical risks, as assessed by using D’Amico’s definition for risk grouping, was as follows: low (4), intermediate (5), and high (11). Three patients received 32 Gy, 7 patients received 34 Gy, and 10 patients received 36 Gy. All patients received the radiation doses in 4 fractions. The rectal and bladder toxicities were graded by using the criteria set forth by the Radiation Therapy Oncology Group (RTOG). Results: The mean patient age was 71.4 years (range, 52-79 years), and the mean follow-up period was 35.5 months (range, 8-74 months). There were 2 acute and 1 late grade 2 gastrointestinal toxicities, and 1 acute and 2 late grade 2 urinary toxicities. The 5-year overall survival rate was 100%, respectively. The 5-year biochemical failure-free rate of the low-risk, intermediate-risk, and high-risk patients was 100%, 100%, and 90.9%, respectively. Conclusions: CyberKnifeTM is a safe, well-tolerated, and rather effective treatment for non-metastatic prostate cancer. We obtained a 100% 5-year biochemical failure-free rate in low-risk and intermediate-risk patients. CyberKnifeTM is a viable option for the treatment of non-metastatic prostate cancer. © The Korean Urological Association, 2009.
“Location, Extent and Number of Positive Surgical Margins Do Not Improve Accuracy of Predicting Prostate Cancer Recurrence After Radical Prostatectomy.”
Stephenson, A. J., D. P. Wood, et al. (2009).
Journal of Urology 182(4 SUPPL.): 1357-1363.
Purpose: Positive surgical margins increase the risk of biochemical recurrence after radical prostatectomy by 2 to 4-fold. The risk of biochemical recurrence may be influenced by the anatomical location and extent of positive surgical margins. In a multicenter study we analyzed the predictive usefulness of several subclassifications of positive surgical margins. Materials and Methods: The clinical information and followup data of 7,160 patients treated with radical prostatectomy alone at 1 of 3 institutions between 1995 and 2006 were modeled using Cox proportional hazards regression analysis for biochemical recurrence. Positive surgical margins were analyzed as solitary vs multiple, focal vs extensive and apical location vs other. The usefulness of these subclassifications was assessed by the improvement in predictive accuracy of nomograms containing these parameters compared to one in which the surgical margin was modeled simply as positive vs negative. Results: The 7-year progression-free probability was 60% in patients with positive surgical margins. A positive surgical margin was significantly associated with biochemical recurrence (HR 2.3, p <0.001) after adjusting for age, prostate specific antigen, pathological Gleason score, pathological stage and year of surgery. An increased risk of biochemical recurrence was associated with multiple vs solitary positive surgical margins (adjusted HR 1.4, p = 0.002) and extensive vs focal positive surgical margins (adjusted HR 1.3, p = 0.004) on multivariable analysis. However, neither parameter improved the predictive accuracy of a nomogram compared to one in which surgical margin status was modeled as positive vs negative (concordance index 0.851 vs 0.850 vs 0.850). Conclusions: The number and extent of positive surgical margin significantly influence the risk of biochemical recurrence after radical prostatectomy. However, the empirical prognostic usefulness of subclassifications of positive surgical margins is limited. © 2009 American Urological Association.
“The accordion severity grading system of surgical complications.”
Strasberg, S. M., D. C. Linehan, et al. (2009).
Annals of Surgery 250(2): 177-186.
Background: A severity grading system is essential to reporting surgical complications. In 1992, we presented such a system (T92). Its use and that of systems derived from it have increased exponentially. Our purpose was to determine how well T92 and its modifications have functioned as a severity grading system and to develop an improved system for reporting complications. Methods: 129 articles were studied in detail. Twenty variables were searched for in each article with particular emphasis on type of study, substitution of qualitative terms for grades, grade compression, and cut-points if grade compression was used. We also determined relative distribution of complications and manner of presentation of complications. Results: T92 and derivative classifications have received wide use in surgical studies ranging from small studies with few complications to large studies of complex operations that describe many complications. There is a strong tendency to contract classifications and to substitute terms with self evident meaning for the numerical grades. Complications are presented in a large variety of tabular forms some of which are much easier to follow than others. Conclusions: Current methods for reporting the severity of complications incompletely fulfill the needs of authors of surgical studies. A new system-the Accordion Severity Grading System-is presented. The Accordion system can be used more readily for small as well as large studies. It introduces standard definition of simple quantitative terms and presents a standard tabular reporting system. This system should bring the field closer to a common severity grading method for surgical complications. © 2009 Lippincott Williams & Wilkins, Inc.
“Erectile function recovery rate after radical prostatectomy: A meta-analysis.”
Tal, R., H. H. Alphs, et al. (2009).
Journal of Sexual Medicine 6(9): 2538-2546.
Introduction. Erectile function recovery (EFR) rates after radical prostatectomy (RP) vary greatly based on a number of factors, such as erectile dysfunction (ED) definition, data acquisition means, time-point postsurgery, and population studied. Aim. To conduct a meta-analysis of carefully selected reports from the available literature to define the EFR rate post-RP. Main Outcome Measures. EFR rate after RP. Methods. An EMBASE and MEDLINE search was conducted for the time range 1985-2007. Articles were assessed blindly by strict inclusion criteria: report of EFR data post-RP, study population ≥ 50 patients, ≥ 1 year follow-up, nerve-sparing status declared, no presurgery ED, and no other prostate cancer therapy. Meta-analysis was conducted to determine the EFR rate and relative risks (RR) for dichotomous subgroups. Results. A total of 212 relevant studies were identified; only 22 (10%) met the inclusion criteria and were analyzed (9,965 RPs, EFR data: 4,983 subjects). Mean study population size: 226.5, standard deviation = 384.1 (range: 17-1,834). Overall EFR rate was 58%. Single center series publications (k = 19) reported a higher EFR rate compared with multicenter series publications (k = 3): 60% vs. 33%, RR = 1.82, P = 0.001. Studies reporting ≥ 18-month follow-up (k = 10) reported higher EFR rate vs. studies with <18-month follow-up (k = 12), 60% vs. 56%, RR = 1.07, P = 0.02. Open RP (k = 16) and laparoscopic RP (k = 4) had similar EFR (57% vs. 58%), while robot-assisted RP resulted in a higher EFR rate (k = 2), 73% compared with these other approaches, P = 0.001. Patients <60 years old had a higher EFR rate vs. patients ≥ 60 years, 77% vs. 61%, RR = 1.26, P = 0.001. Conclusions. These data indicate that most of the published literature does not meet strict criteria for reporting post-RP EFR. Single and multiple surgeon series have comparable EFR rates, but single center studies have a higher EFR. Younger men have higher EFR and no significant difference in EFR between ORP and LRP is evident. © 2009 International Society for Sexual Medicine.
“Impact of prostate weight on radical prostatectomy outcomes.”
Tal, R., M. Konichezky, et al. (2009).
Israel Medical Association Journal 11(6): 354-358.
Background: The management of localized prostate cancer in patients with large prostates is controversial. Objectives: To investigate the impact of prostate weight on radical prostatectomy outcomes. Methods: The files of 244 patients who underwent radical prostatectomy were reviewed. Data were collected on patient and tumor characteristics and on oncological, urinary and erectile function outcomes. Results were compared between patients with prostates weighing ≤ 60 g or > 60 g. Results: A prostate weight of > 60 g was documented in 25% of the patients. There was no difference in clinical stage distribution between patients with smaller and patients with larger prostates. Patients with a larger prostate were characterized preoperatively by higher levels of prostatespecific antigen (9.8 vs. 7.3 ng/ml, P = 0.009), lower tumor grade (biopsy Gleason score ≤ 6: 77.6% vs. 90.2% P = 0.04), and a higher incidence of moderate-severe urinary symptoms (69.8 vs. 38.8%, P = 0.0003). Analysis of pathological stage distribution yielded a higher proportion of lower stage disease and a lower incidence of positive margins in the large-prostate group (11.7 vs. 25.8%, P = 0.024). There were no statistically significant between-group differences in the rate of persistent postoperative detectable PSA, biochemical recurrence, urinary incontinence and erectile function. Conclusions: The outcomes of radical prostatectomy in patients with large prostate are favorable in terms of cancer characteristics despite their higher preoperative PSA levels, and comparable to that in patients with small prostate in terms of urinary continence and erectile function. Surgery may be particularly beneficial in patients with preoperative urinary symptoms. Hence, radical prostatectomy should not be discouraged as a treatment for localized prostate cancer in patients with sizeable prostates.
“Ultrasensitive prostate specific antigen assay following laparoscopic radical prostatectomy–an outcome measure for defining the learning curve.”
Viney, R., L. Gommersall, et al. (2009).
Annals of the Royal College of Surgeons of England 91(5): 399-403.
INTRODUCTION: Radical retropubic prostatectomy (RRP) performed laparoscopically is a popular treatment with curative intent for organ-confined prostate cancer. After surgery, prostate specific antigen (PSA) levels drop to low levels which can be measured with ultrasensitive assays. This has been described in the literature for open RRP but not for laparoscopic RRP. This paper describes PSA changes in the first 300 consecutive patients undergoing non-robotic laparoscopic RRP by a single surgeon. OBJECTIVES: To use ultrasensitive PSA (uPSA) assays to measure a PSA nadir in patients having laparoscopic radical prostatectomy below levels recorded by standard assays. The aim was to use uPSA nadir at 3 months’ post-prostatectomy as an early surrogate end-point of oncological outcome. In so doing, laparoscopic oncological outcomes could then be compared with published results from other open radical prostatectomy series with similar end-points. Furthermore, this end-point could be used in the assessment of the surgeon’s learning curve. PATIENTS AND METHODS: Prospective, comprehensive, demographic, clinical, biochemical and operative data were collected from all patients undergoing non-robotic laparoscopic RRP. We present data from the first 300 consecutive patients undergoing laparoscopic RRP by a single surgeon. uPSA was measured every 3 months post surgery. RESULTS: Median follow-up was 29 months (minimum 3 months). The likelihood of reaching a uPSA of < or = 0.01 ng/ml at 3 months is 73% for the first 100 patients. This is statistically lower when compared with 83% (P < 0.05) for the second 100 patients and 80% for the third 100 patients (P < 0.05). Overall, 84% of patients with pT2 disease and 66% patients with pT3 disease had a uPSA of < or = 0.01 ng/ml at 3 months. Pre-operative PSA, PSA density and Gleason score were not correlated with outcome as determined by a uPSA of < or = 0.01 ng/ml at 3 months. Positive margins correlate with outcome as determined by a uPSA of < or = 0.01 ng/ml at 3 months but operative time and tumour volume do not (P < 0.05). Attempt at nerve sparing had no adverse effect on achieving a uPSA of < or = 0.01 ng/ml at 3 months. CONCLUSIONS: uPSA can be used as an early end-point in the analysis of oncological outcomes after radical prostatectomy. It is one of many measures that can be used in calculating a surgeon’s learning curve for laparoscopic radical prostatectomy and in bench-marking performance. With experience, a surgeon can achieve in excess of an 80% chance of obtaining a uPSA nadir of < or = 0.01 ng/ml at 3 months after laparoscopic RRP for a British population. This is equivalent to most published open series.
“Current status of robotic assisted pelvic surgery and future developments.”
Ahmed, K., M. S. Khan, et al. (2009).
Int J Surg.
AIMS: The aim of this review is to assess the role of robotics in pelvic surgery in terms of outcomes. We have also highlighted the issues related to training and future development of robotic systems. MATERIALS AND METHODS: We searched MEDLINE, EMBASE and the Cochrane Databases from 1980 to 2009 for systematic reviews of randomised controlled trials, prospective observational studies, retrospective studies and case reports assessing robotic surgery. RESULTS: During the last decade, there has been a tremendous rise in the use of robotic surgical systems for all forms of precision operations including pelvic surgery. The short-term results of robotic pelvic surgery in the fields of urology, colorectal surgery and gynaecology have been shown to be comparable to the laparoscopic and open surgery. Robotic surgery offers an opportunity where many of these obstacles encountered during open and laparoscopic surgery can be overcome. CONCLUSIONS: Robotic surgery is a continually advancing technology, which has opened new horizons for performing pelvic surgery with precision and accuracy. Although its use is rapidly expanding in all surgical disciplines, particularly in pelvic surgery, further comparative studies are needed to provide robust guidance about the most appropriate application of this technology within the surgical armamentarium.
“Video-games station or minimally invasive skills training station?”
Alnajjar, H. M. and J. Virdi (2009).
BJU International 104(7): 1020.
“Robotic laparoscopic surgery: Cost and training.”
Amodeo, A., A. Linares Quevedo, et al. (2009).
Minerva Urologica e Nefrologica 61(2): 121-128.
The advantages of minimally invasive surgery are well accepted. Shorter hospital stays, decreased postoperative pain, rapid return to preoperative activity, decreased postoperative ileus, and preserved immune function are among the benefits of the laparoscopic approach. However, the instruments of laparoscopy afford surgeons limited precision and poor ergonomics, and their use is associated with a significant learning curve and the amount of time and energy necessary to develop and maintain such advanced laparoscopic skills is not insignificant. The robotic surgery allows all laparoscopists to perform advanced laparoscopic procedures with greater ease. The potential advantages of surgical robotic systems include making advanced laparoscopic surgical procedures accessible to surgeons who do not have advanced video endoscopic training and broadening the scope of surgical procedures that can be performed using the laparoscopic method. The wristed instruments, x10 magnifications, tremor filtering, scaling of movements and three-dimensional view allow the urologist to perform the intricate dissection and anastomosis with high precision. The robot is not, however, without significant disadvantages as compared with traditional laparoscopy. These include greater expense and consumption of operating room resources such as space and the availability of skilled technical staff, complete elimination of tactile feedback, and more limited options for trocar placement. The current cost of the da Vinci system is $ 1.2 million and annual maintenance is $ 138 000. Many studies suggest that depreciation and maintenance costs can be minimised if the number of robotic cases is increased. The high cost of purchasing and maintaining the instruments of the robotic system is one of its many disadvantages. The availability of the robotic systems to only a limited number of centres reduces surgical training opportunities. Hospital administrators and surgeons must define the reasons for developing a robotic surgical program: it is very important to show that robotics will add a dimension that will benefit the hospital, the patient care and institutional recognition. Another essential task to overcome is the important education of the operating room nursing staff, a significant difference between this modality and traditional surgery. Without operating room environment support, most surgeons will revert to traditional methods even after a few successful robotics cases. As the field of robotic surgery continues to grow, graduate medical education and continuing medical education programs that address the surgical robotic learning needs of residents and practicing surgeons need to be developed.
“Rise of the machines.”
Basu, I. (2009).
International Journal of Surgery 7(4): 399-400.
“Bringing Da Vinci to dentistry.”
Bonett, J. B. (2009).
The Penn dental journal 5(2): 2-5.
“The clavien-dindo classification of surgical complications: Five-year experience.”
Clavien, P. A., J. Barkun, et al. (2009).
Annals of Surgery 250(2): 187-196.
Background and Aims: The lack of consensus on how to define and grade adverse postoperative events has greatly hampered the evaluation of surgical procedures. A new classification of complications, initiated in 1992, was updated 5 years ago. It is based on the type of therapy needed to correct the complication. The principle of the classification was to be simple, reproducible, flexible, and applicable irrespective of the cultural background. The aim of the current study was to critically evaluate this classification from the perspective of its use in the literature, by assessing interobserver variability in grading complex complication scenarios and to correlate the classification grades with patients’, nurses’, and doctors’ perception. Material and Methods: Reports from the literature using the classification system were systematically analyzed. Next, 11 scenarios illustrating difficult cases were prepared to develop a consensus on how to rank the various complications. Third, 7 centers from different continents, having routinely used the classification, independently assessed the 11 scenarios. An agreement analysis was performed to test the accuracy and reliability of the classification. Finally, the perception of the severity was tested in patients, nurses, and physicians by presenting 30 scenarios, each illustrating a specific grade of complication. Results: We noted a dramatic increase in the use of the classification in many fields of surgery. About half of the studies used the contracted form, whereas the rest used the full range of grading. Two-thirds of the publications avoided subjective terms such as minor or major complications. The study of 11 difficult cases among various centers revealed a high degree of agreement in identifying and ranking complications (89% agreement), and enabled a better definition of unclear situations. Each grade of complications significantly correlated with the perception by patients, nurses, and physicians (P < 0.05, Kruskal-Wallis test). Conclusions: This 5-year evaluation provides strong evidence that the classification is valid and applicable worldwide in many fields of surgery. No modification in the general principle of classification is warranted in view of the use in ongoing publications and trials. Subjective, inaccurate, or confusing terms such as “minor or major” should be removed from the surgical literature. © 2009 Lippincott Williams & Wilkins, Inc.
“Impact of IQ, computer-gaming skills, general dexterity, and laparoscopic experience on performance with the da Vinci surgical system.”
Hagen, M. E., O. J. Wagner, et al. (2009).
Int J Med Robot 5(3): 327-331.
BACKGROUND: Due to improved ergonomics and dexterity, robotic surgery is promoted as being easily performed by surgeons with no special skills necessary. We tested this hypothesis by measuring IQ elements, computer gaming skills, general dexterity with chopsticks, and evaluating laparoscopic experience in correlation to performance ability with the da Vinci robot. METHODS: Thirty-four individuals were tested for robotic dexterity, IQ elements, computer-gaming skills and general dexterity. Eighteen surgically inexperienced and 16 laparoscopically trained surgeons were included. Each individual performed three different tasks with the da Vinci surgical system and their times were recorded. An IQ test (elements: logical thinking, 3D imagination and technical understanding) was completed by each participant. Computer skills were tested with a simple computer game (hand-eye coordination) and general dexterity was evaluated by the ability to use chopsticks. RESULTS: We found no correlation between logical thinking, 3D imagination and robotic skills. Both computer gaming and general dexterity showed a slight but non-significant improvement in performance with the da Vinci robot (p > 0.05). A significant correlation between robotic skills, technical understanding and laparoscopic experience was observed (p < 0.05). CONCLUSIONS: The data support the conclusion that there are no significant correlations between robotic performance and logical thinking, 3D understanding, computer gaming skills and general dexterity. A correlation between robotic skills and technical understanding may exist. Laparoscopic experience seems to be the strongest predictor of performance with the da Vinci surgical system. Generally, it appears difficult to determine non-surgical predictors for robotic surgery.
“Simulation modeling for the health care manager.”
Kennedy, M. H. (2009).
Health Care Manager 28(3): 246-252.
This article addresses the use of simulation software to solve administrative problems faced by health care managers. Spreadsheet add-ins, process simulation software, and discrete event simulation software are available at a range of costs and complexity. All use the Monte Carlo method to realistically integrate probability distributions into models of the health care environment. Problems typically addressed by health care simulation modeling are facility planning, resource allocation, staffing, patient flow and wait time, routing and transportation, supply chain management, and process improvement. © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins.
“The future of robotics in hand surgery.”
Liverneaux, P., E. Nectoux, et al. (2009).
Chirurgie de la Main.
Robotics has spread over many surgical fields over the last decade: orthopaedic, cardiovascular, urologic, gynaecologic surgery and various other types of surgery. There are five different types of robots: passive, semiactive and active robots, telemanipulators and simulators. Hand surgery is at a crossroad between orthopaedic surgery, plastic surgery and microsurgery; it has to deal with fixing all sorts of tissues from bone to soft tissues. To our knowledge, there is not any paper focusing on potential clinical applications in this realm, even though robotics could be helpful for hand surgery. One must point out the numerous works on bone tissue with regard to passive robots (such as fluoroscopic navigation as an ancillary for percutaneous screwing in the scaphoid bone). Telemanipulators, especially in microsurgery, can improve surgical motion by suppressing physiological tremor thanks to movement demultiplication (experimental vascular and nervous sutures previously published). To date, the robotic technology has not yet become simple-to-use, cheap and flawless but in the future, it will probably be of great technical help, and even allow remote-controlled surgery overseas. © 2009 Elsevier Masson SAS. All rights reserved.
“Robotic and laparoscopic surgery: cost and training.”
Patel, H. R., A. Linares, et al. (2009).
Surg Oncol 18(3): 242-246.
Robotic prostatectomy training as part of mainstream surgical training will be difficult. The primary problems revolve around the inconsistencies of standard sugery. Many surgeons are still in the learning curve, as is the understanding of the true capabilities of the robot. The important elements of robotic surgery actually enhance basic laparoscopic techniques. The prostate has been shown to be an organ where this new technology has a niche. As we move toward cross specialty use the robot although extremely expensive, may be the best way to train the laparoscopic surgeon of the future.
“Training requirements and credentialing for laparoscopic and robotic surgery–what are our responsibilities?”
Schwartz, B. F. (2009).
J Urol 182(3): 828-829.
“The accordion severity grading system of surgical complications.”
Strasberg, S. M., D. C. Linehan, et al. (2009).
Annals of Surgery 250(2): 177-186.
Background: A severity grading system is essential to reporting surgical complications. In 1992, we presented such a system (T92). Its use and that of systems derived from it have increased exponentially. Our purpose was to determine how well T92 and its modifications have functioned as a severity grading system and to develop an improved system for reporting complications. Methods: 129 articles were studied in detail. Twenty variables were searched for in each article with particular emphasis on type of study, substitution of qualitative terms for grades, grade compression, and cut-points if grade compression was used. We also determined relative distribution of complications and manner of presentation of complications. Results: T92 and derivative classifications have received wide use in surgical studies ranging from small studies with few complications to large studies of complex operations that describe many complications. There is a strong tendency to contract classifications and to substitute terms with self evident meaning for the numerical grades. Complications are presented in a large variety of tabular forms some of which are much easier to follow than others. Conclusions: Current methods for reporting the severity of complications incompletely fulfill the needs of authors of surgical studies. A new system-the Accordion Severity Grading System-is presented. The Accordion system can be used more readily for small as well as large studies. It introduces standard definition of simple quantitative terms and presents a standard tabular reporting system. This system should bring the field closer to a common severity grading method for surgical complications. © 2009 Lippincott Williams & Wilkins, Inc.
“Assessing the Impact of Ischaemia Time During Partial Nephrectomy.”
Becker, F., H. Van Poppel, et al. (2009).
European Urology 56(4): 625-635.
Context: The impact of applying renal ischaemia during nephron-sparing surgery to avoid renal damage in the treated kidney has gained importance in different surgical techniques. Objective: The main objective of the present study is to point out the limit of renal ischaemia times for warm and cold ischaemia approaches. Important results of research on renal ischaemia and different surgical techniques as well as results of clinical studies concerning renal function after renal ischaemia in partial nephrectomy are highlighted. Evidence acquisition: A Medline literature research was performed, combining queries on the keywords nephron-sparing surgery, partial nephrectomy, and ischemia. Links to related articles and cross-reading of citations in related articles were surveyed, as were reviews, letters to editors, and information collected from urologic textbooks. The references formed the basis of this review article, with selection and deletion based on the relevance and importance of the content. In a final step, interactive peer review by the expert panel of coauthors completed the review. Evidence synthesis: Renal ischaemia research showed an increasing renal damage proportional to ischemic time. Current clinical data support safe ischaemia times, within 20 min of warm ischaemia and up to 2 h of cold ischaemia, to minimise renal ischemic damage. To date, no ischaemia dose-response curve or algorithm is available to predict the risk of acute kidney injury and chronic kidney disease in patients undergoing intraoperative ischaemia. In general, there seems to be a higher risk for comorbidity caused by renal damage in patients suffering from kidney tumour. Conclusions: If ischaemia is required, the tumour should be removed within 20 min of warm ischaemia, regardless of surgical approach. Efforts should be made to start immediately with cold ischaemia, if the feasibility within this span of time seems to be jeopardised. Thus, cold ischaemia times up to 2 h can be tolerated by the kidney, depending on the individual method. Nevertheless, cold ischaemia with ice slush should be kept as short as possible-at best within 35 min. In ischemic nephron-sparing surgery, one of the surgeon’s main aims should be to avoid loss of renal function. Only after optimal preoperative appraisal and planning can the best postoperative outcomes for renal function be achieved. © 2009 European Association of Urology.
“Delayed Prostate-specific Antigen Recurrence After Radical Prostatectomy: How to Identify and What Are Their Clinical Outcomes?”
Caire, A. A., L. Sun, et al. (2009).
Urology 74(3): 643-647.
Objectives: To identify factors that predict delayed (> 5 years) prostate-specific antigen recurrence (PSAR) after radical prostatectomy (RP) and to analyze the associated clinical outcomes. Methods: A cohort of 4561 men who underwent RP between 1988 and 2008 was retrieved from the Duke University Prostate Center database. Among them, 1207 (26.5%) had PSAR and were included in this study. The cohort was then divided into 2 groups; PSAR before 5 years (early PSAR) and PSAR after 5 years (delayed PSAR), and Kaplan Meier analysis was performed. Univariate and logistic regression analysis was carried out to determine significant predictors of delayed PSAR, using factors such as race, age, body mass index, PSA, surgical margin status, pathologic Gleason sum, pathologic tumor stage, and prostate weight. Results: There was a marginal difference between the early and delayed PSAR groups with regard to metastasis-free survival (P = .062). A significant difference in disease-specific survival was found between the 2 groups (P = .025). Patients with pathologic Gleason sums < 7 were more likely to have delayed PSAR as compared to those with pathologic Gleason sums > 7 (OR = 2.38). Patients with a PSA < 10 ng/mL were more likely to have delayed PSAR in comparison to those with PSA > 20 ng/mL (OR = 2.38). Conclusions: Approximately 90% of PSAR occurred within 5 years after RP. Lower pathologic Gleason sums and lower PSA at diagnosis were associated with delayed PSAR. Patients with delayed PSAR have a disease-specific survival advantage as compared to men with early PSAR. © 2009 Elsevier Inc. All rights reserved.
“Laparoscopy and gynecologic oncology.”
Cho, J. E., C. Liu, et al. (2009).
Clinical Obstetrics and Gynecology 52(3): 313-326.
Laparoscopy was used for a second-look assessment in ovarian cancer patients back in the 1970s. However, it is only with the advent of new developments in equipment in the late 1980s and early 1990s along with the vision of pioneers in laparoscopic surgery that has made operative laparoscopy in gynecologic oncology feasible. Laparoscopy has multiple benefits in the cancer patients, including image magnification to visualize metastatic or recurrent disease and improved dissection in challenging areas such as the paravesical and pararectal spaces. There is limited bleeding from small vessels because of the pressure from pneumoperitoneum, decreased hospital stay, and rapid recovery. Postoperative chemotherapy or radiation can be initiated earlier, and radiation complications from bowel adhesions are minimized. Significant progress has been made in the last 2 decades in gynecologic malignancy. In this study, the application of laparoscopy in cervical, endometrial, and ovarian cancer will be presented. © 2009 Lippincott Williams & Wilkins, Inc.
“The clavien-dindo classification of surgical complications: Five-year experience.”
Clavien, P. A., J. Barkun, et al. (2009).
Annals of Surgery 250(2): 187-196.
Background and Aims: The lack of consensus on how to define and grade adverse postoperative events has greatly hampered the evaluation of surgical procedures. A new classification of complications, initiated in 1992, was updated 5 years ago. It is based on the type of therapy needed to correct the complication. The principle of the classification was to be simple, reproducible, flexible, and applicable irrespective of the cultural background. The aim of the current study was to critically evaluate this classification from the perspective of its use in the literature, by assessing interobserver variability in grading complex complication scenarios and to correlate the classification grades with patients’, nurses’, and doctors’ perception. Material and Methods: Reports from the literature using the classification system were systematically analyzed. Next, 11 scenarios illustrating difficult cases were prepared to develop a consensus on how to rank the various complications. Third, 7 centers from different continents, having routinely used the classification, independently assessed the 11 scenarios. An agreement analysis was performed to test the accuracy and reliability of the classification. Finally, the perception of the severity was tested in patients, nurses, and physicians by presenting 30 scenarios, each illustrating a specific grade of complication. Results: We noted a dramatic increase in the use of the classification in many fields of surgery. About half of the studies used the contracted form, whereas the rest used the full range of grading. Two-thirds of the publications avoided subjective terms such as minor or major complications. The study of 11 difficult cases among various centers revealed a high degree of agreement in identifying and ranking complications (89% agreement), and enabled a better definition of unclear situations. Each grade of complications significantly correlated with the perception by patients, nurses, and physicians (P < 0.05, Kruskal-Wallis test). Conclusions: This 5-year evaluation provides strong evidence that the classification is valid and applicable worldwide in many fields of surgery. No modification in the general principle of classification is warranted in view of the use in ongoing publications and trials. Subjective, inaccurate, or confusing terms such as “minor or major” should be removed from the surgical literature. © 2009 Lippincott Williams & Wilkins, Inc.
“Novel treatment methods for localized prostate cancer: Hypofractionated robotic radiation therapy and adjuvant hemotherapy.”
Dawson, N. A. and S. P. Collins (2009).
Expert Review of Anticancer Therapy 9(7): 953-962.
The standard localized therapies for prostate cancer include external-beam radiation therapy, brachytherapy and radical prostatectomy. There are several novel approaches in development aimed at improving local disease control and survival, and reducing post-treatment complications. In low-to-intermediate-risk patients, new radiation approaches are being explored to include hypofractionated robotic radiation therapy. For high-risk patients, the focus is on multimodality approaches, especially the addition of chemotherapy. Recent developments in radiation therapy and adjuvant chemotherapy are the focus of this review. © 2009 Expert Reviews Ltd.
“Stereotactic body radiotherapy: an emerging treatment approach for localized prostate cancer.”
Friedland, J. L., D. E. Freeman, et al. (2009).
Technol Cancer Res Treat 8(5): 387-392.
Here we report results from the first cohort of over 100 patients treated with hypofractionated, stereotactic body radiotherapy (SBRT) for early stage prostate cancer. Between February 2005 and December 2006, 112 patients with localized, biopsy-proven adenocarcinoma of the prostate (clinical stage T1cN0M0 to T2cN0M0) were treated in Naples, FL on a CyberKnife system (Accuray Incorporated, Sunnyvale, CA). Eighty-one patients had a Gleason score of 3+3. Mean initial PSA was 6.0, and mean initial prostate volume was 46.3cc. Implanted gold fiducials were used for image-guided targeting and tracking. Patients received 35-36 Gy administered in 5 consecutive fractions to the prostate and the proximal seminal vesicles, as identified on CT and MRI scans. At a median follow-up of 24 months, the mean PSA value was 0.78 ng/ml. Two patients have developed biopsy-confirmed local relapse; one developed distant metastases. Acute side effects were generally mild and resolved shortly after treatment. A single Grade 3 rectal complication was reported (bleeding). Eighty-two percent of patients who were sexually potent before treatment maintained erectile function post-treatment. Additional follow-up is required to better evaluate potential late toxicity and long-term PSA outcomes.
“Simulation modeling for the health care manager.”
Kennedy, M. H. (2009).
Health Care Manager 28(3): 246-252.
This article addresses the use of simulation software to solve administrative problems faced by health care managers. Spreadsheet add-ins, process simulation software, and discrete event simulation software are available at a range of costs and complexity. All use the Monte Carlo method to realistically integrate probability distributions into models of the health care environment. Problems typically addressed by health care simulation modeling are facility planning, resource allocation, staffing, patient flow and wait time, routing and transportation, supply chain management, and process improvement. © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins.
“CyberknifeTM for the treatment of non-metastatic prostate cancer.”
Lee, S. J., K. Song, et al. (2009).
Korean Journal of Urology 50(8): 744-750.
Purpose: The radiobiology of prostate cancer favors a hypofractionated dose regimen. We report here our experience with the CyberKnifeTM, demonstrating its efficacy, safety, and feasibility as a treatment modality for non-metastatic prostate cancer. Materials and Methods: Between October 2002 and April 2006, 20 patients with biopsy-proven prostate cancer were treated with the CyberKnifeTM. The distribution of clinical risks, as assessed by using D’Amico’s definition for risk grouping, was as follows: low (4), intermediate (5), and high (11). Three patients received 32 Gy, 7 patients received 34 Gy, and 10 patients received 36 Gy. All patients received the radiation doses in 4 fractions. The rectal and bladder toxicities were graded by using the criteria set forth by the Radiation Therapy Oncology Group (RTOG). Results: The mean patient age was 71.4 years (range, 52-79 years), and the mean follow-up period was 35.5 months (range, 8-74 months). There were 2 acute and 1 late grade 2 gastrointestinal toxicities, and 1 acute and 2 late grade 2 urinary toxicities. The 5-year overall survival rate was 100%, respectively. The 5-year biochemical failure-free rate of the low-risk, intermediate-risk, and high-risk patients was 100%, 100%, and 90.9%, respectively. Conclusions: CyberKnifeTM is a safe, well-tolerated, and rather effective treatment for non-metastatic prostate cancer. We obtained a 100% 5-year biochemical failure-free rate in low-risk and intermediate-risk patients. CyberKnifeTM is a viable option for the treatment of non-metastatic prostate cancer. © The Korean Urological Association, 2009.
“Location, Extent and Number of Positive Surgical Margins Do Not Improve Accuracy of Predicting Prostate Cancer Recurrence After Radical Prostatectomy.”
Stephenson, A. J., D. P. Wood, et al. (2009).
Journal of Urology 182(4 SUPPL.): 1357-1363.
Purpose: Positive surgical margins increase the risk of biochemical recurrence after radical prostatectomy by 2 to 4-fold. The risk of biochemical recurrence may be influenced by the anatomical location and extent of positive surgical margins. In a multicenter study we analyzed the predictive usefulness of several subclassifications of positive surgical margins. Materials and Methods: The clinical information and followup data of 7,160 patients treated with radical prostatectomy alone at 1 of 3 institutions between 1995 and 2006 were modeled using Cox proportional hazards regression analysis for biochemical recurrence. Positive surgical margins were analyzed as solitary vs multiple, focal vs extensive and apical location vs other. The usefulness of these subclassifications was assessed by the improvement in predictive accuracy of nomograms containing these parameters compared to one in which the surgical margin was modeled simply as positive vs negative. Results: The 7-year progression-free probability was 60% in patients with positive surgical margins. A positive surgical margin was significantly associated with biochemical recurrence (HR 2.3, p <0.001) after adjusting for age, prostate specific antigen, pathological Gleason score, pathological stage and year of surgery. An increased risk of biochemical recurrence was associated with multiple vs solitary positive surgical margins (adjusted HR 1.4, p = 0.002) and extensive vs focal positive surgical margins (adjusted HR 1.3, p = 0.004) on multivariable analysis. However, neither parameter improved the predictive accuracy of a nomogram compared to one in which surgical margin status was modeled as positive vs negative (concordance index 0.851 vs 0.850 vs 0.850). Conclusions: The number and extent of positive surgical margin significantly influence the risk of biochemical recurrence after radical prostatectomy. However, the empirical prognostic usefulness of subclassifications of positive surgical margins is limited. © 2009 American Urological Association.
“The accordion severity grading system of surgical complications.”
Strasberg, S. M., D. C. Linehan, et al. (2009).
Annals of Surgery 250(2): 177-186.
Background: A severity grading system is essential to reporting surgical complications. In 1992, we presented such a system (T92). Its use and that of systems derived from it have increased exponentially. Our purpose was to determine how well T92 and its modifications have functioned as a severity grading system and to develop an improved system for reporting complications. Methods: 129 articles were studied in detail. Twenty variables were searched for in each article with particular emphasis on type of study, substitution of qualitative terms for grades, grade compression, and cut-points if grade compression was used. We also determined relative distribution of complications and manner of presentation of complications. Results: T92 and derivative classifications have received wide use in surgical studies ranging from small studies with few complications to large studies of complex operations that describe many complications. There is a strong tendency to contract classifications and to substitute terms with self evident meaning for the numerical grades. Complications are presented in a large variety of tabular forms some of which are much easier to follow than others. Conclusions: Current methods for reporting the severity of complications incompletely fulfill the needs of authors of surgical studies. A new system-the Accordion Severity Grading System-is presented. The Accordion system can be used more readily for small as well as large studies. It introduces standard definition of simple quantitative terms and presents a standard tabular reporting system. This system should bring the field closer to a common severity grading method for surgical complications. © 2009 Lippincott Williams & Wilkins, Inc.
“Erectile function recovery rate after radical prostatectomy: A meta-analysis.”
Tal, R., H. H. Alphs, et al. (2009).
Journal of Sexual Medicine 6(9): 2538-2546.
Introduction. Erectile function recovery (EFR) rates after radical prostatectomy (RP) vary greatly based on a number of factors, such as erectile dysfunction (ED) definition, data acquisition means, time-point postsurgery, and population studied. Aim. To conduct a meta-analysis of carefully selected reports from the available literature to define the EFR rate post-RP. Main Outcome Measures. EFR rate after RP. Methods. An EMBASE and MEDLINE search was conducted for the time range 1985-2007. Articles were assessed blindly by strict inclusion criteria: report of EFR data post-RP, study population ≥ 50 patients, ≥ 1 year follow-up, nerve-sparing status declared, no presurgery ED, and no other prostate cancer therapy. Meta-analysis was conducted to determine the EFR rate and relative risks (RR) for dichotomous subgroups. Results. A total of 212 relevant studies were identified; only 22 (10%) met the inclusion criteria and were analyzed (9,965 RPs, EFR data: 4,983 subjects). Mean study population size: 226.5, standard deviation = 384.1 (range: 17-1,834). Overall EFR rate was 58%. Single center series publications (k = 19) reported a higher EFR rate compared with multicenter series publications (k = 3): 60% vs. 33%, RR = 1.82, P = 0.001. Studies reporting ≥ 18-month follow-up (k = 10) reported higher EFR rate vs. studies with <18-month follow-up (k = 12), 60% vs. 56%, RR = 1.07, P = 0.02. Open RP (k = 16) and laparoscopic RP (k = 4) had similar EFR (57% vs. 58%), while robot-assisted RP resulted in a higher EFR rate (k = 2), 73% compared with these other approaches, P = 0.001. Patients <60 years old had a higher EFR rate vs. patients ≥ 60 years, 77% vs. 61%, RR = 1.26, P = 0.001. Conclusions. These data indicate that most of the published literature does not meet strict criteria for reporting post-RP EFR. Single and multiple surgeon series have comparable EFR rates, but single center studies have a higher EFR. Younger men have higher EFR and no significant difference in EFR between ORP and LRP is evident. © 2009 International Society for Sexual Medicine.
“Impact of prostate weight on radical prostatectomy outcomes.”
Tal, R., M. Konichezky, et al. (2009).
Israel Medical Association Journal 11(6): 354-358.
Background: The management of localized prostate cancer in patients with large prostates is controversial. Objectives: To investigate the impact of prostate weight on radical prostatectomy outcomes. Methods: The files of 244 patients who underwent radical prostatectomy were reviewed. Data were collected on patient and tumor characteristics and on oncological, urinary and erectile function outcomes. Results were compared between patients with prostates weighing ≤ 60 g or > 60 g. Results: A prostate weight of > 60 g was documented in 25% of the patients. There was no difference in clinical stage distribution between patients with smaller and patients with larger prostates. Patients with a larger prostate were characterized preoperatively by higher levels of prostatespecific antigen (9.8 vs. 7.3 ng/ml, P = 0.009), lower tumor grade (biopsy Gleason score ≤ 6: 77.6% vs. 90.2% P = 0.04), and a higher incidence of moderate-severe urinary symptoms (69.8 vs. 38.8%, P = 0.0003). Analysis of pathological stage distribution yielded a higher proportion of lower stage disease and a lower incidence of positive margins in the large-prostate group (11.7 vs. 25.8%, P = 0.024). There were no statistically significant between-group differences in the rate of persistent postoperative detectable PSA, biochemical recurrence, urinary incontinence and erectile function. Conclusions: The outcomes of radical prostatectomy in patients with large prostate are favorable in terms of cancer characteristics despite their higher preoperative PSA levels, and comparable to that in patients with small prostate in terms of urinary continence and erectile function. Surgery may be particularly beneficial in patients with preoperative urinary symptoms. Hence, radical prostatectomy should not be discouraged as a treatment for localized prostate cancer in patients with sizeable prostates.
“Ultrasensitive prostate specific antigen assay following laparoscopic radical prostatectomy–an outcome measure for defining the learning curve.”
Viney, R., L. Gommersall, et al. (2009).
Annals of the Royal College of Surgeons of England 91(5): 399-403.
INTRODUCTION: Radical retropubic prostatectomy (RRP) performed laparoscopically is a popular treatment with curative intent for organ-confined prostate cancer. After surgery, prostate specific antigen (PSA) levels drop to low levels which can be measured with ultrasensitive assays. This has been described in the literature for open RRP but not for laparoscopic RRP. This paper describes PSA changes in the first 300 consecutive patients undergoing non-robotic laparoscopic RRP by a single surgeon. OBJECTIVES: To use ultrasensitive PSA (uPSA) assays to measure a PSA nadir in patients having laparoscopic radical prostatectomy below levels recorded by standard assays. The aim was to use uPSA nadir at 3 months’ post-prostatectomy as an early surrogate end-point of oncological outcome. In so doing, laparoscopic oncological outcomes could then be compared with published results from other open radical prostatectomy series with similar end-points. Furthermore, this end-point could be used in the assessment of the surgeon’s learning curve. PATIENTS AND METHODS: Prospective, comprehensive, demographic, clinical, biochemical and operative data were collected from all patients undergoing non-robotic laparoscopic RRP. We present data from the first 300 consecutive patients undergoing laparoscopic RRP by a single surgeon. uPSA was measured every 3 months post surgery. RESULTS: Median follow-up was 29 months (minimum 3 months). The likelihood of reaching a uPSA of < or = 0.01 ng/ml at 3 months is 73% for the first 100 patients. This is statistically lower when compared with 83% (P < 0.05) for the second 100 patients and 80% for the third 100 patients (P < 0.05). Overall, 84% of patients with pT2 disease and 66% patients with pT3 disease had a uPSA of < or = 0.01 ng/ml at 3 months. Pre-operative PSA, PSA density and Gleason score were not correlated with outcome as determined by a uPSA of < or = 0.01 ng/ml at 3 months. Positive margins correlate with outcome as determined by a uPSA of < or = 0.01 ng/ml at 3 months but operative time and tumour volume do not (P < 0.05). Attempt at nerve sparing had no adverse effect on achieving a uPSA of < or = 0.01 ng/ml at 3 months. CONCLUSIONS: uPSA can be used as an early end-point in the analysis of oncological outcomes after radical prostatectomy. It is one of many measures that can be used in calculating a surgeon’s learning curve for laparoscopic radical prostatectomy and in bench-marking performance. With experience, a surgeon can achieve in excess of an 80% chance of obtaining a uPSA nadir of < or = 0.01 ng/ml at 3 months after laparoscopic RRP for a British population. This is equivalent to most published open series.