In this study, we investigate the effect of trainee involvement on surgical performance, as measured by automated performance metrics (APMs), and outcomes after robot-assisted radical prostatectomy (RARP).
We compared APMs (instrument tracking, EndoWrist® articulation, and system events data) and clinical outcomes for cases with varying resident involvement. Four of 12 standardized RARP steps were designated critical (“cardinal”) steps. Comparison 1: cases where the attending surgeon performed all four cardinal steps (Group A) and cases where a trainee was involved in at least one cardinal step (Group B). Comparison 2, where Group A is split into Groups C and D: cases where attending performs the whole case (Group C) vs. cases where a trainee performed at least one non-cardinal step (Group D). Mann–Whitney U and Chi-squared tests were used for comparisons.
Comparison 1 showed significant differences in APM profiles including camera movement time, third instrument usage, dominant instrument moving time, velocity, articulation, as well as non-dominant instrument moving time and articulation (all favoring Group A p < 0.05). There was a significant difference in re-admission rates (10.9% in Group A vs 0% in Group B, p < 0.02), but not for post-operative outcomes. Comparison 2 demonstrated a significant difference in dominant instrument articulation (p < 0.05) but not in post-operative outcomes.
Trainee involvement in RARP is safe. The degree of trainee involvement does not significantly affect major clinical outcomes. APM profiles are less efficient when trainees perform at least one cardinal step but not during non-cardinal steps.
This is a preview of subscription content, access via your institution.
Buy single article
Instant access to the full article PDF.
Tax calculation will be finalised during checkout.
Subscribe to journal
Immediate online access to all issues from 2019. Subscription will auto renew annually.
Tax calculation will be finalised during checkout.
Birkmeyer JD, Finks JF, O'Reilly A, Oerline M, Carlin AM, Nunn AR, Dimick J, Banerjee M, Birkmeyer NJ, Michigan Bariatric Surgery C (2013) Surgical skill and complication rates after bariatric surgery. N Engl J Med 369(15):1434–1442. https://doi.org/10.1056/NEJMsa1300625
Castleberry AW, Clary BM, Migaly J, Worni M, Ferranti JM, Pappas TN, Scarborough JE (2013) Resident education in the era of patient safety: a nationwide analysis of outcomes and complications in resident-assisted oncologic surgery. Ann Surg Oncol 20(12):3715–3724. https://doi.org/10.1245/s10434-013-3079-2
Raval MV, Wang X, Cohen ME, Ingraham AM, Bentrem DJ, Dimick JB, Flynn T, Hall BL, Ko CY (2011) The influence of resident involvement on surgical outcomes. J Am Coll Surg 212(5):889–898. https://doi.org/10.1016/j.jamcollsurg.2010.12.029
Matulewicz RS, Pilecki M, Rambachan A, Kim JY, Kundu SD (2014) Impact of resident involvement on urological surgery outcomes: an analysis of 40,000 patients from the ACS NSQIP database. J Urol 192(3):885–890. https://doi.org/10.1016/j.juro.2014.03.096
Ruhotina N, Dagenais J, Gandaglia G, Sood A, Abdollah F, Chang SL, Leow JJ, Olugbade K Jr, Rai A, Sammon JD, Schmid M, Varda B, Zorn KC, Menon M, Kibel AS, Trinh QD (2014) The impact of resident involvement in minimally-invasive urologic oncology procedures. Can Urol Assoc J 8(9–10):334–340. https://doi.org/10.5489/cuaj.2170
Allard CB, Meyer CP, Gandaglia G, Chang SL, Chun FK, Gelpi-Hammerschmidt F, Hanske J, Kibel AS, Preston MA, Trinh QD (2015) The effect of resident involvement on perioperative outcomes in transurethral urologic surgeries. J Surg Educ 72(5):1018–1025. https://doi.org/10.1016/j.jsurg.2015.04.012
Caveney M, Matthews C, Mirzazadeh M (2017) The effect of resident involvement in pelvic prolapse surgery: a retrospective study from a nationwide inpatient sample. Female Pelvic Med Reconstr Surg 23(6):387–391. https://doi.org/10.1097/SPV.0000000000000436
Hung AJ, Oh PJ, Chen J, Ghodoussipour S, Lane C, Jarc A, Gill IS (2019) Experts vs super-experts: differences in automated performance metrics and clinical outcomes for robot-assisted radical prostatectomy. BJU Int 123(5):861–868. https://doi.org/10.1111/bju.14599
Chen J, Cheng N, Cacciamani G, Oh P, Lin-Brande M, Remulla D, Gill IS, Hung AJ (2019) Objective assessment of robotic surgical technical skill: a systematic review. J Urol 201(3):461–469. https://doi.org/10.1016/j.juro.2018.06.078
Hung AJ, Chen J, Jarc A, Hatcher D, Djaladat H, Gill IS (2018) Development and validation of objective performance metrics for robot-assisted radical prostatectomy: a pilot study. J Urol 199(1):296–304. https://doi.org/10.1016/j.juro.2017.07.081
Hung AJ, Chen J, Ghodoussipour S, Oh PJ, Liu Z, Nguyen J, Purushotham S, Gill IS, Liu Y (2019) A deep-learning model using automated performance metrics and clinical features to predict urinary continence recovery after robot-assisted radical prostatectomy. BJU Int. https://doi.org/10.1111/bju.14735
Patel VR, Sivaraman A, Coelho RF, Chauhan S, Palmer KJ, Orvieto MA, Camacho I, Coughlin G, Rocco B (2011) Pentafecta: a new concept for reporting outcomes of robot-assisted laparoscopic radical prostatectomy. Eur Urol 59(5):702–707. https://doi.org/10.1016/j.eururo.2011.01.032
Herrell SD, Smith JA Jr (2005) Robotic-assisted laparoscopic prostatectomy: what is the learning curve? Urology 66(5 Suppl):105–107. https://doi.org/10.1016/j.urology.2005.06.084
Research reported in this publication was supported in part by the National Institute of Biomedical Imaging And Bioengineering of the National Institutes of Health under Award Number K23EB026493 and an Intuitive Surgical Clinical Research Grant. Anthony Jarc and Liheng Guo (Intuitive Surgical, Inc.) assisted with automated performance metric processing.
Conflict of interest
The study was supported in part by an Intuitive Surgical, Inc. clinical grant. Intuitive Surgical, Inc. provided the systems events data recorder.
Human and animals rights
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. This article does not contain any studies with animals performed by any of the authors.
Informed consent was obtained from all individual participants included in the study.
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
About this article
Cite this article
Chen, A., Ghodoussipour, S., Titus, M.B. et al. Comparison of clinical outcomes and automated performance metrics in robot-assisted radical prostatectomy with and without trainee involvement. World J Urol 38, 1615–1621 (2020). https://doi.org/10.1007/s00345-019-03010-3
- Automatic performance metrics
- Resident surgical training
- Surgical education
- Robotic surgical procedures