Goldenberg Mitchell G, Goldenberg Larry, Grantcharov Teodor P
1 Division of Urology, University of Toronto , Toronto, Canada .
2 Department of Urologic Sciences, University of British Columbia , Vancouver, Canada .
J Endourol. 2017 Sep;31(9):858-863. doi: 10.1089/end.2017.0284. Epub 2017 Jun 26.
There is limited, yet compelling evidence supporting the role of surgeon technical performance in influencing patient outcomes. To date, this concept has been underexplored in endourologic procedures. We hypothesized that a surgeon's technical performance plays a role in predicting an early return to continence after robot-assisted radical prostatectomy (RARP).
We conducted a retrospective, matched case-control analysis of prospectively collected unedited RARP endoscopic videos performed by a single surgeon. A blinded observer with expertise in intraoperative video analysis evaluated clinically relevant steps of RARP using the global evaluative assessment of robotic skill (GEARS) and the generic error rating tool (GERT). The primary outcome was continence status at 3 months postoperatively, defined as patient use of less than or equal to a single precautionary pad. Mann-Whitney U tests examined differences in predictor variables between cases and controls, and multivariate analysis was conducted using binary logistic regression models.
Twenty-four incontinent patients were matched for age, body mass index, preoperative International Prostate Symptoms Score, use of posterior/anterior hitch, prostate weight, and learning curve position. No statistically significant difference in errors between groups was observed using the GERT. On multivariate analysis, overall case GEARS score was independently predictive of 3-month continence status (odds ratios [OR] = 0.55, 95% confidence interval [CI] 0.33-0.91), as were urethrovesical anastomosis (OR = 0.70, 95% CI 0.50-0.97) and bladder neck GEARS scores (OR = 0.69, 95% CI 0.51-0.94).
Our study generates the hypothesis that there may be a link between surgeon technical performance and functional outcomes in RARP. This relationship may have implications for the accreditation and training of future urologists and warrants further investigation.
支持外科医生技术操作在影响患者预后方面作用的证据有限，但令人信服。迄今为止，这一概念在内腔泌尿外科手术中尚未得到充分探索。我们假设外科医生的技术操作在预测机器人辅助根治性前列腺切除术（RARP）后早期恢复控尿方面发挥作用。
我们对由一名外科医生前瞻性收集的未经编辑的RARP内镜视频进行了回顾性、匹配病例对照分析。一名具有术中视频分析专业知识的盲法观察者使用机器人技能全球评估（GEARS）和通用错误评分工具（GERT）评估RARP的临床相关步骤。主要结局是术后3个月的控尿状态，定义为患者使用不超过一片预防性尿垫。曼-惠特尼U检验检查病例组和对照组之间预测变量的差异，并使用二元逻辑回归模型进行多变量分析。
24名尿失禁患者在年龄、体重指数、术前国际前列腺症状评分、使用后/前悬吊术、前列腺重量和学习曲线位置方面进行了匹配。使用GERT未观察到两组之间在错误方面有统计学显著差异。多变量分析显示，总体病例GEARS评分独立预测3个月控尿状态（优势比[OR]=0.55，95%置信区间[CI]0.33 - 0.91），尿道膀胱吻合术（OR=0.70，95%CI 0.50 - 0.97）和膀胱颈GEARS评分（OR=0.69，95%CI 0.51 - 0.94）也具有预测作用。
我们的研究提出了一个假设，即外科医生技术操作与RARP的功能结局之间可能存在联系。这种关系可能对未来泌尿外科医生的认证和培训有影响，值得进一步研究。
