Using Video Analysis to Understand the Technical Variation of Robot-Assisted Radical Prostatectomy (RARP) in a Statewide Surgical Collaborative
Ghani K, Patel P, Kim T, Prebay Z, Telang J, Linsell S, Kleer E, Miller D, Peabody J, and Johnston W. Using Video Analysis to Understand the Technical Variation of Robot-Assisted Radical Prostatectomy (RARP) in a Statewide Surgical Collaborative. Eur Urol, Supplements 2018; 17(2):e1861-e1862.
Eur Urol Suppl
Introduction & Objectives: Video assessment is an emerging tool for understanding variation in surgical technique. Despite widespread adoption, patient outcomes after RARP may be linked to technical aspects of the procedure. In an effort to refine surgical approaches and improve outcomes, we sought to understand technical variation for the steps of RARP in a surgical collaborative. Materials & Methods: The Michigan Urological Surgery Improvement Collaborative (MUSIC) is a statewide quality improvement collaborative consisting of 260 urologists from 44 diverse community and academic practices, with the aim of improving prostate cancer care. Surgeons were invited to submit representative complete videos of nerve-sparing RARP to the MUSIC coordinating center. The duration and variation in the tasks performed during each part were captured. Results: The anterior approach was used by 65%, with the remainder using a posterior approach for the seminal vesicle (SV) dissection. Data obtained from video analysis identified variation in time to complete different steps (Figure 1): bladder takedown (2-24 mins), endopelvic fascia dissection (4-11 mins), dorsal venous complex (DVC) control (2-10 mins), bladder neck dissection (7- 30 mins), SV dissection (9 -32 mins), nerve-sparing and pedicle control (8-33 mins), apical dissection (4-17 mins), and anastomosis (17-44 mins). Seven different permutations involving suture, staples and electrocautery for dividing and controlling the DVC were used. Management of the pedicle and nerve-sparing was performed using hem-o-lok clips (75%), Enseal tissue sealer (20%), and titanium clips (5%). Prior to anastomosis, only 25% undertook a posterior reconstruction. A non-barbed (vs. barbed) running suture (60%) was the main method when completing the anastomosis, overall 30% placed a urethral suspension stitch. At the end, 50% of surgeons performed a bladder leak test with 11/20 surgeons placing drains regardless of the result. Two surgeons utilized suprapubic tubes for bladder drainage (vs urethral catheter). Conclusions: RARP technique is not uniform. Video analysis identified variation in (1) time to complete each step (2) methods for DVC control, (3) nerve-sparing technique, and (4) performance of the urethrovesical anastomosis. Future efforts linking differences in technique with clinical outcomes may provide objective evidence to support best practices. (figure presented).