3,476 research outputs found

    A core outcome set for localised prostate cancer effectiveness trials

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    Objective: To develop a core outcome set (COS) applicable for effectiveness trials of all interventions for localised prostate cancer. Background: Many treatments exist for localised prostate cancer, although it is unclear which offers the optimal therapeutic ratio. This is confounded by inconsistencies in the selection, definition, measurement and reporting of outcomes in clinical trials. Subjects and methods: A list of 79 outcomes was derived from a systematic review of published localised prostate cancer effectiveness studies and semi-structured interviews with 15 prostate cancer patients. A two-stage consensus process involving 118 patients and 56 international healthcare professionals (HCPs) (cancer specialist nurses, urological surgeons and oncologists) was undertaken, consisting of a three-round Delphi survey followed by a face-to-face consensus panel meeting of 13 HCPs and 8 patients. Results: The final COS included 19 outcomes. Twelve apply to all interventions: death from prostate cancer, death from any cause, local disease recurrence, distant disease recurrence/metastases, disease progression, need for salvage therapy, overall quality of life, stress urinary incontinence, urinary function, bowel function, faecal incontinence, sexual function. Seven were intervention-specific: perioperative deaths (surgery), positive surgical margin (surgery), thromboembolic disease (surgery), bothersome or symptomatic urethral or anastomotic stricture (surgery), need for curative treatment (active surveillance), treatment failure (ablative therapy), and side effects of hormonal therapy (hormone therapy). The UK-centric participants may limit the generalisability to other countries, but trialists should reason why the COS would not be applicable. The default position should not be that a COS developed in one country will automatically not be applicable elsewhere. Conclusion: We have established a COS for trials of effectiveness in localised prostate cancer, applicable across all interventions which should be measured in all localised prostate cancer effectiveness trials

    Medical image computing and computer-aided medical interventions applied to soft tissues. Work in progress in urology

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    Until recently, Computer-Aided Medical Interventions (CAMI) and Medical Robotics have focused on rigid and non deformable anatomical structures. Nowadays, special attention is paid to soft tissues, raising complex issues due to their mobility and deformation. Mini-invasive digestive surgery was probably one of the first fields where soft tissues were handled through the development of simulators, tracking of anatomical structures and specific assistance robots. However, other clinical domains, for instance urology, are concerned. Indeed, laparoscopic surgery, new tumour destruction techniques (e.g. HIFU, radiofrequency, or cryoablation), increasingly early detection of cancer, and use of interventional and diagnostic imaging modalities, recently opened new challenges to the urologist and scientists involved in CAMI. This resulted in the last five years in a very significant increase of research and developments of computer-aided urology systems. In this paper, we propose a description of the main problems related to computer-aided diagnostic and therapy of soft tissues and give a survey of the different types of assistance offered to the urologist: robotization, image fusion, surgical navigation. Both research projects and operational industrial systems are discussed

    Positive surgical margins in nephron-sparing surgery; the great unknown

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    There is a currently a general trend towards organ-preserving surgery, and urology is no exception. Specifically, nephron-sparing surgery (NSS) has gained general acceptance for T1a renal cell carcinoma (guidelines recommendations). Moreover T1b, T2 and even T3 stage tumors have been included on the nephron sparing list at some centers. An unresolved issue is that of positive surgical margins (PSM), not only their detection but also the implications for follow up and treatment. This paper highlights data available on risk factors for PSM, their clinical relevance, and possible therapeutic consequences. From the surgeon’s viewpoint, NSS is a daring and risky surgical procedure. Urological guidelines stress the importance of NSS, and thus the trend is moving in that direction. Unresolved, however, is the problem of PSM. Trifecta, MIC, and pentafecta are applicable concepts which attempt to define the optimal endpoint of NSS, but further elaboration is necessary. Specifically, research needs to focus less on the concept of definitive margins and more on their identification and avoidance. Although some studies suggest that PSMs do not influence overall survival rate, the basic idea of preserving tissue that is not cancerous leads to further medical, social, and psychological considerations

    Outcomes of a virtual-reality simulator-training programme on basic surgical skills in robot-assisted laparoscopic surgery

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    Background The utility of the virtual-reality robotic simulator in training programmes has not been clearly evaluated. Our aim was to evaluate the impact of a virtual-reality robotic simulator-training programme on basic surgical skills. Methods A simulator-training programme in robotic surgery, using the da Vinci Skills Simulator, was evaluated in a population including junior and seasoned surgeons, and non-physicians. Their performances on robotic dots and suturing-skin pod platforms before and after virtual-simulation training were rated anonymously by surgeons experienced in robotics. Results 39 participants were enrolled: 14 medical students and residents in surgery, 14 seasoned surgeons, 11 non-physicians. Junior and seasoned surgeons’ performances on platforms were not significantly improved after virtual-reality robotic simulation in any of the skill domains, in contrast to non-physicians. Conclusions The benefits of virtual-reality simulator training on several tasks to basic skills in robotic surgery were not obvious among surgeons in our initial and early experience with the simulator

    Robotic-Assisted Surgery for Benign Urological Conditions

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    Robotic technology for use in surgery has advanced considerably in the past 10 years. This has become particularly apparent in urology where robotic-assisted radical prostatectomy using the da VinciTM surgical system (Intuitive Surgical, CA) has become very popular. The use of robotic assistance for benign urological procedures is less well documented. This article considers the current robotic technology and reviews the situation with regard to robotic surgery for benign urological conditions

    Robotic partial nephrectomy for posterior tumors through a retroperitoneal approach offers decreased length of stay compared with the transperitoneal approach: A propensity-matched analysis

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    INTRODUCTION: We sought to compare surgical outcomes between transperitoneal and retroperitoneal robotic partial nephrectomy (RPN) for posterior tumors. PATIENTS AND METHODS: Using our multi-institutional RPN database, we reviewed 610 consecutive cases for posterior renal masses treated between 2007 and 2015. Primary outcomes were complications, operative time, length of stay (LOS), surgical margin status, and estimated glomerular filtration rate (eGFR) preservation. Secondary outcomes were estimated blood loss, warm ischemia time (WIT), disease recurrence, and disease-specific mortality. Due to significant differences in treatment year and tumor size between approaches, retroperitoneal cases were matched 1:4 to transperitoneal cases based on propensity scores using the greedy algorithm. Outcomes were compared between approaches using the chi-square and Mann-Whitney U tests. RESULTS: After matching, 296 transperitoneal and 74 retroperitoneal cases were available for analysis, and matched groups were well balanced in terms of treatment year, age, gender, race, American Society of Anesthesiologists physical status classification (ASA) score, body mass index, tumor laterality, tumor size, R.E.N.A.L. (radius, exophytic/endophytic properties, nearness of tumor to the collecting system or sinus, anterior/posterior, location relative to polar lines) score, and hilar location. Compared with transperitoneal, the retroperitoneal approach was associated with significantly shorter mean LOS (2.2 vs 2.6 days, p = 0.01), but longer mean WIT (21 vs 19 minutes, p = 0.01). Intraoperative (p = 0.35) and postoperative complications (p = 0.65), operative time (p = 0.93), positive margins (p = 1.0), and latest eGFR preservation (p = 0.25) were not significantly different between approaches. No differences were detected in the other outcomes. CONCLUSIONS: Among high-volume surgeons, transperitoneal and retroperitoneal RPN achieved similar outcomes for posterior renal masses, although with slight differences in LOS and WIT. Retroperitoneal RPN may be an effective option for the treatment of certain small posterior renal masses

    Extended pelvic lymph node dissection at the time of robot-assisted radical prostatectomy: Impact of surgical volume on efficacy and complications in a single-surgeon series

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    INTRODUCTION: We assessed the impact of surgical volume on perioperative outcomes and complications of robotic extended pelvic lymph node dissection (ePLND). METHODS: From November 2008 to October 2012, a total of 233 consecutive patients with intermediate- or high-risk clinically localized prostate cancer underwent robot-assisted radical prostatectomy (RARP) and ePLND by a single, experienced open and laparoscopic surgeon. Data were prospectively collected. Complications were classified according to the Modified Clavien System. Complications potentially related to ePLND were documented. The minimum follow-up was 3 months. To evaluate the impact of surgical volume on the results, 4 patient subgroups (subgroup 1: cases 1-59; 2: 60-117; 3: 118-175; 4: 176-233) were compared using the Chi-squared and Kruskal-Wallis tests. RESULTS: The mean (range) operative time for ePLND was 79 minutes (range: 48-144), with a steady performance over time (p = 0.784). The count of resected lymph nodes plateaued after 60 procedures (mean [range]: 13 [range: 6-32], 15 [range: 7-34], 17 [range: 8-41], 16 [range: 8-42] in Groups 1 to 4, respectively, p = 0.001). Tumour lymph node involvement was 12% in Groups 1 and 2, 7% in Group 3 and 9% in Group 4 (p = 0.075). Overall, 115 complications were reported in 98/233 patients (42%), with a significant decrease after 175 cases (p = 0.028). In Group 4, 3 patients reported an ePLND-related bleeding requiring open revision. Lymphoceles were detected in 10/233 patients (4.2%) and 1 patient (1.7%) in each of the Groups 2 to 4 required a percutaneous drainage. CONCLUSIONS: A surgeon with extensive experience is expected to achieve a safe learning curve for ePLND during RARP. A learning curve of 60 cases is suggested for optimal lymph node yield
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