Oral Presentations - European Urology Supplements

EUROPEAN UROLOGY SUPPLEMENTS 14 (2015) No. 5

a v a i l a b l e a t w w w. s c i e n c e d i r e c t . c o m j o u r n a l h o m e p a g e : w w w. e u r o p e a n u r o l o g y. c o m

ISSN 1569-9056

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Volume 14, Issue 5, September 2015

EUROPEAN UROLOGY

SUPPLEMENTS EU-ACME accredited content

Programme and abstracts of the 12th Meeting of the EAU Robotic Urology Section (ERUS) 15-17 September 2015, Bilbao, Spain

European Association of Urology

Oral Presentations Oral presentations Oral presentations Junior ERUS-YAU nominees – Poster abstracts (PJY04-PJY08-PJY12) PJY04 Simulation-based robotic surgery training: Validation of the RobotiX mentor simulator

(p=0.015), and number of suture breakages (p=0.038). Participants determined both the simulator console and psychomotor tasks as highly realistic (mean: 3.8/5) and very important for surgical training (4.4/5), with diathermy pedals (4.5/5) and knot tying task (4.6/5) scoring highest respectively. The simulator was also rated as an acceptable (4.3/5) tool for training and its use highly feasible (4.4/5).

Aydin A., Whittaker G., Raison N., Challacombe B., Khan M., Dasgupta P., Ahmed K. King’s College London, Dept. of MRC Centre for Transplantation, London, United Kingdom Introduction and objectives: With robot-assisted surgery becoming more common practice in urology, effective training remains a challenge. Simulation has gained wide acceptance as a method of reducing the initial phase of the learning curve. This study aims to assess face, content and construct validity of the RobotiX Mentor virtual reality simulator. It also aims to assess its acceptability as a training tool and feasibility of its use in training. Material and methods: This prospective, observational and comparative study recruited novice (n=20), intermediate (n=11) and expert (n=8) robotic surgeons as participants from institutions across the United Kingdom. Each participant completed nine surgical tasks across two modules on the simulator, followed by a questionnaire to evaluate subjective realism (face validity), task importance (content validity), feasibility, and acceptability. Outcome measures of novice, intermediate and expert groups were compared using Mann-Whitney U-tests to assess construct validity.

Conclusions: The RobotiX Mentor shows potential as a valuable tool for training and assessment of trainees in robotic skills and may reduce the initial learning curve if utilised as an adjunct to operating-room training. Investigation of concurrent and predictive validity is necessary to complete validation and evaluation of learning curves would provide insight into its value for training. PJY08 Single surgeon perioperative and early continence results of initial 52 cases after graduating ‘ERUS Robotic Urology Curriculum Fellowship’ (Pilot Study II) for robot-assisted radical prostatectomy (RARP)

Results: Construct validity was demonstrated in a total of 17/25 performance evaluation metrics (p2mm deep (p=0.035), average distance from suture target

Salwa P., Wagner C., Schuette A., Addali M., Harke N.N., Witt J. St. Antonius-Hospital, Academic Teaching Hospital Affiliated To The University Münster, Dept. of Urology, Pediatric Urology and Urologic Oncology, Gronau, Germany Introduction and objectives: No validated curriculum for robotic surgery exists so far. The ERUS Pilot Study II aimed at validating the ability of a 6 month structured training program to allow a novice surgeon to perform a complete RARP independently and

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ORAL PRESENTATIONS / EUROPEAN UROLOGY SUPPLEMENTS 14 (2015) 79–143

effectively. Here, we report perioperative efficacy and safety results of initial 52 full cases performed by single surgeon after graduating from fellowship. Material and methods: The fellowship was conducted from January to June 2014. It consisted of e-learning, bedside assistances, intensive training consisting of lectures on technical and non-technical skills, laboratory training (virtual reality simulation, dry lab, wet lab on dog cadaver and living anaesthetized pigs) and dual-console live surgery followed by a 5-month modular training at host center. After passing the final evaluation (a full case of RARP was evaluated blindly by robotic experts) the trainee was deemed capable of performing a full case of RARP. Here we report the perioperative and early continence results of initial 52 cases performed from July 2014 to April 2015. Results: During initial 10 months after graduating from the Pilot Study II, 52 cases of RARP were performed. Mean age was 65.2 years, BMI 27.5 kg/m2, initial PSA 12.9 ng/ml and a prostate volume of 43.7 ml in TRUS, 61% of patients had a prior abdominal or pelvic surgery. A pelvic lymphadenectomy was performed in every case and 3 patients showed positive lymph nodes. The mean console time was 174.2 minutes. Estimated blood loss was 225.7 ml. 29 patients (55.8%) had a local confined disease (T2) in the final pathology, with positive surgical margin in 2 cases. 23 patients (44.2%) had a locally advanced prostate cancer (T3 or T4) with a positive margin in three cases (one T3 and two T4 cases). Catheter was removed on the 5th postoperative day after inconspicuous cystogram in 96.2% of cases. We observed one major (Clavien 4) and 13 minor (Clavien 1 and 2 i.e. urinary retention, skin allergic reaction and uncomplicated urinary infection) complications. Follow-up with validated questionnaires after 3 months was available in 12 patients, with 9 patients using 0 or 1, whereas 3 patients need 2 or more safety pads. Age (years) BMI (kg/m2) TRUS (ml) Prior abdominal/pelvic surgery (%) Mean iPSA-Value (ng/ml) Average console time (min) Estimated blood loss (ml) Mean catheterization time (days) T2 T3 T4 N+ Positive surgical margin in all cases (%) in T2 cases in T3/T4 cases

65.2 27.5 43.7 61 12.9 174.2 225.7 5.5 55.8% 40.4% 3.8% 5.8% 9,6% 6.9% 13.0%

Conclusions: After graduating from ERUS Robotic Urology Curriculum Fellowship – Pilot Study II, a fellow was able to perform 52 RARPs in a safe and efficient manner despite the fact that 44% of the patients had a locally advanced disease. Early continence results are promising, however complete functional recovery could better be assessed after longer (i.e. 12 months after surgery) follow-up. Further limitation of this report is a moderate number of performed cases.

PJY12 Multi-institutional development and validation of the RARP score for training and assessment Lovegrove C.E.1, Novara G2, Guru K.3, Mottrie A.4, Challacombe B.1, Raza J.3, Van Der Poel H.5, Peabody J.6, Popert R.6, Dasgupta P.1, Ahmed K.1 1Guy’s Hospital, Dept. of Urology, London, United Kingdom, 2University of Padua, Dept. of Urology, Padua, Italy, 3 Roswell Park Cancer Institute, Dept. of Urology, Buffalo, United States of America, 4OLV Hospital, Dept. of Urology, Aalst, Belgium, 5 Netherlands Cancer Institute, Dept. of Urology, Amsterdam, The Netherlands, 6Henry Ford Hosiptal, Dept. of Urology, Detroit, United States of America Introduction and objectives: Robot assisted surgical training and assessment are critical in assuring optimal outcomes. This study aims to: (1) develop and validate a check-list based training and assessment tool (RARP Score); (2) Evaluate learning curve (LC) of the RARP using RARP score. Material and methods: This multi-institutional, observational, prospective study used HFMEA (Healthcare Failure Mode and Effect Analysis) to identify high risk, critical steps of RARP. A, focus group of specialists was consulted to develop and content validate the RARP Score. Following development, 15 trainees performed RARP cases and were assessed by mentors using this tool. Previously, full follow-up results were unavailable for analysis. The full data-set was analysed relative to RARP experience to examine learning curves for each step. A LC plateau above “Score 4” was indicative of competence for a given step. Results: 5 surgeons were observed for 42 console hours to map steps of RARP. HFMEA identified 84 failure modes and 46 potential causes with “Hazard score” ≥8. Content validation by experts (US, UK, Europe) created the RARP Score of 17 stages and 41 steps (Figure 1). This was acceptable, feasible with educational impact.


15 trainees were assessed for 8 months. They participated in 426 RARP cases (Range 4-79) and, all 17 procedural steps were attempted. Of reported data, the majority of cases were T stage 2 (40.3%), N stage 0 (59.9%) and “Intermediate” D’Amico risk (36.1%). Learning curves derived demonstrated several findings. Of note were plateaus for Anterior Bladder Neck Transection (16 cases), Posterior Bladder Neck Transection (18 cases- Figure 2.), Posterior Dissection (9 cases), Dissection of Prostatic Pedicle and Seminal Vesicles (15 cases) and Anastomosis (17 cases). For the rest of the steps the LC did not plateau for the data collection period (e.g. Expose Prostatic Apex and Endopelvic Fascia; 31 cases, Stitching and Division of Dorsal Venous Plexus; 32 cases).

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vas deferens. The ureter is dissected distal to the vas and tented up with a tape. After that left ureter was clipped and sutured with a 3-0 vicryl suture in watertight fashion. Tailoring for the dilated distal rest ureter is performed. The bladder is elevated with suture through the abdominal wall. A 4 cm detrusorotomy is performed. Mucosa is cut for anastomosis. 6 F nelaton catheter is placed through urethra and bladder inside the left tailored ureter. Ureterovesical anastomosis is made with a 4-0 monocryl suture. Detrusorraphy is performed by a 3-0 barbed suture. The parietal peritoneum closed. Foley catheter, nelaton catheter and drain are left at the end of the procedure. Results: Console time for the operation was 82 minutes for our unilateral case. No perioperative complications were seen. Perioperative blood loss was minimal and postoperative pain was none. 11-month result of this patient is satisfactory. He has normal urine flow through left ureterovesical junction. Conclusions: RALUR is a technically feasible approach for VUR, UVS and the other ureteral pathologies. With this video presentation we tried to explain the technique of tailoring and RALUR and wanted to recommend usage of barbed suture for detrusorraphy. We think to accept this technique as an alternative of open repair it is needed larger case series of tailoring and RALUR according to the literature. VJY04 Tips and tricks in robotic prostatectomy: Appropriate endoscope selection to bail you out of challenging cases Fuentes Pastor J., Sridhar A., Goldstraw M., Lamb B.W., Cathcart P., Senthil N., Kelly J., Timothy B. University College London Hospital (UCLH), Dept. of Urology, London, United Kingdom

Conclusions: RARP score based on HFMEA methodology identified critical hazardous steps specific to RARP and was used to assess and evaluate surgeons while performing RARP. The learning curves derived demonstrate the experience necessary to reach competence in essential technical skills required to protect patient safety. Oral presentations Oral presentations Junior ERUS-YAU nominees – Video abstracts (VJY01-VJY04-VJY06) VJY01 Robot assisted laparoscopic left ureteral reimplantation for uretero-vesical stricture Yalcin S., Kibar Y. Gülhane Military Medical Academy, Dept. of Urology, Ankara, Turkey Introduction and objectives: Extravesical robot-assisted laparoscopic ureteral reimplantation (RALUR) for ureterovesical strictures (UVS) is an alternative to the gold standard open repair. With this video presentation we want to share our initial experience for a 5 year old boy patient who is the youngest patient received this intervention in Turkey. Material and methods: We have performed 8 RALUR procedure for adult and pediatric patients in our clinic. This patient explained in the video was a 5-year-old boy who has had recurrent infections due to this condution. When the patient applied to our clinic he had already grade 4 left ureterohydronephrosis. We performed left sided RALUR procedure for this patient. Technique: The DaVinci SI system was used via a transperitoneal approach. We used a 4 port configuration for the procedure. Modified Trendelenburg (approximately 10o) position was used. Following docking, the ureter is identified closed to the

Introduction and objectives: The 3- dimensional endoscopic view is central to robot assisted laparoscopic surgery. Visualization of critical strictures ateach step of the procedure is essential for precise dissection and in turn favourable outcomes. The 0 0 scope does not always provide complete visualization of anatomy. This video demonstrates the use of the 30 0 angled lens for improved visualization in challenging scenarios. Material and methods: We expose in the video how the use of different positions of the 30º angle scope (30º up/30º down) can be helpful during different steps of robotic radical prostatectomy: Bladder neck dissection, dissection of the seminal vesicles and bladder neck reconstruction. Results: We show in the video how the use of 30º down scope is useful in the bladder neck dissection providing better view, also in the dissection of the seminal vesicles and in the bladder neck reconstruction. On the other hand the use of 30º up scope might be helpful in the dissection of the puboprostatic ligaments and the dorsal vein complex in patients with prominent pubic bone. Conclusions: Use of the 30º angle scope is helpful during challenging cases. Identifying when to use one or the other will help to achieve better result during the surgery. VJY06 Laparoscopic robot-assisted heminephrectomy in a patient with left duplex collector system and ectopic uretrocele to vagina Morales Higelmo G., Gutierrez Garcia M.A., Estebanez Zarranz J., Belloso Loidi J., Cano Restrepo C., Peralta Durango J.M., Rubio Calaveras V., Sanz Jaka J.P. Donostia Universitary Hospital, Dept. of Urology, San Sebastian, Spain Introduction and objectives: Robot-assisted laparoscopy indications in Urology are increasing. Among thus indications, not only oncological diseases but also benign ones may have an important place.

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We present the case of 44 years-old woman with a left duplex collector system and ectopic ureterocele to vagina, assessed at outpatient clinic due to persistent lumbar pain, dyspareunia and multiple UTIs, to whom we offered robot-assisted laparoscopy to correct the defect. Material and methods: In this 7 minute video we describe the case and the surgery, for which we use the S model Da Vinci robot we have since 2008, using its fourth arm in several movements during the surgery. We first setted up a ureteral catheter in the healthy left ureter. After identifying the upper pole ureter and liberate it we performed the heminephrectomy. Later we released the splitted ureter until we achieved vagina. A main surgeon and an assistant worked with the four arms of the robot, with the essential help of two trained nurses. Results: The patient of the case presented in the video undergoes really a satisfactory recovery after surgery, with minimal bleeding and no complications. Discharge took place only 4 days after the intervention, with completely functional recovery. Conclusions: According to our experience robot-assisted laparoscopy is a good alternative for well selected patients with benign urological disease, such as duplex collector system, who need surgical treatment, with less invasive approach and fast recovery. Oral presentations Oral presentations ERUS – Poster abstracts (PE13-PE18-PE31) PE13 Complications after totally intracorporeal robot-assisted radical cystectomy: Results from the ERUS scientific working group Hosseini A.1, Collins J.W.1, Koupparis A.2, Rowe E.2, Perry M.3, Issa R.3, Adding C.1, Nyberg T.4, Schumacher M.C.5, Wijburg C.6, Canda A.E.7, Balbay M.D.8, Decaestecker K.9, Schwentner C.10, Stenzl A.10, Edeling S.11, Pokupić S.11, Guru K.12, Mottrie A.13, Wiklund N.P.1 1Karolinska, Dept. of Urology, Stockholm, Sweden, 2 Bristol Urological Institute, Dept. of Urology, Bristol, United Kingdom, 3St Georges, Dept. of Urology, London, United Kingdom, 4 Karolinska, Dept. of Clinical Cancer Edpidemiology, Stockholm, Sweden, 5Hirslanden Klinik, Dept. of Urology, Aarau, Switzerland, 6 Rijnstate, Dept. of Urology, Arnham, The Netherlands, 7Ankara Ataturk Hospital, Dept. of Urology, Ankara, Turkey, 8Memorial Sisli Hospital, Dept. of Urology, Istanbul, Turkey, 9Ghent University, Dept. of Urology, Ghent, Belgium, 10University of Tuebingen, Dept. of Urology, Tuebingen, Germany, 11Da Vinci Zentrum, Dept. of Urology, Hanover, Germany, 12Roswell Park Cancer Institute, Dept. of Urology, Buffalo, United States of America, 13O.L.V. Hospital, Dept. of Urology, Aalst, Belgium Introduction and objectives: Radical cystectomy is associated with high complications rates irrespective of surgical approach. Worldwide most centers performing robot-assisted radical cystectomy (RARC) perform an extracorporeal urinary diversion, despite potential advantages of a completely minimally invasive technique. We describe complication outcomes after totally intracorporeal RARC from a multi-institutional database using a standardized and validated reporting methodology. Material and methods: Using the ERUS Scientific Working Group (ESWG) database, we identified 621 patients who underwent totally intracorporeal RARC with at least 90d of follow-up. Complications were analyzed and graded according to the Clavien-Dindo Classification system and were further stratified by organ system. Secondary outcomes included identification of preoperative and intraoperative variables associated with the complications. Logistic regression models were used to define

predictors of complications and readmission, using backward selection (p