Laparoscopy and Robotics Novel Telementoring System for Robot-assisted Radical Prostatectomy: Impact on the Learning Curve Nobuyuki Hinata, Hideaki Miyake, Toshifumi Kurahashi, Makoto Ando, Junya Furukawa, Takeshi Ishimura, Kazushi Tanaka, and Masato Fujisawa OBJECTIVE METHODS
RESULTS
CONCLUSION
To develop a Web-based audiovisual telementoring system for robot-assisted radical prostatectomy (RARP) and to assess the utility of this system. A telementoring system for RARP, consisting of a 3-dimensional high-definition view of the operating field, overview of the operating room, annotation function, and 2-channel audio feed with bidirectional connectivity between 2 institutions, was developed. The outcome of RARP performed for the initial 30 patients by 2 surgeons with telementoring was compared with that for 2 surgeons who received direct mentoring. This system was shown to function properly with an acceptable latency. There were no significant differences in several parameters reflecting surgical outcomes, including the operating time, complication rate, early continence status, and positive margin rate between the telementoring and direct mentoring groups. These findings suggest the usefulness of the telementoring system for promoting the spread of precise surgical techniques associated with RARP. To our knowledge, this is the first report concerning telementoring for robot-assisted surgery. UROLOGY 83: 1088e1092, 2014. 2014 Elsevier Inc.
B
ecause the learning curve for robot-assisted radical prostatectomy (RARP) has been reported to influence oncological and functional outcomes,1,2 mentoring of trainee surgeons has become more important to ensure that they attain sufficient skill without compromising the safety of their initial patients. Mentoring is usually done face-to-face, which presents practical difficulties when the mentor and trainee belong to different institutions. Advances in technology have opened new avenues for long-distance communication through telemedicine. Using such technology, an expert surgeon can observe and actively supervise a procedure performed by a trainee surgeon at another institution. Telementoring is an application of telemedicine that involves the remote guidance of procedures when the operator has limited experience with the technique.3 We constructed a telementoring system for RARP and validated its feasibility. We also examined whether the initial outcomes of RARP
Financial Disclosure: The authors declare that they have no relevant financial interests. From the Department of Urology, Kobe University Graduate School of Medicine, Kobe, Japan; and the Division of Urology, Seirei Mikatahara General Hospital, Hamamatsu, Japan Reprint requests: Nobuyuki Hinata, M.D., Ph.D., Department of Urology, Kobe University Graduate School of Medicine, 7-5-1, Kusunoki-cho, Kobe 650-0017, Japan. E-mail: [email protected] Submitted: August 22, 2013, accepted (with revisions): January 2, 2014
1088
ª 2014 Elsevier Inc. All Rights Reserved
performed by trainee surgeons were similar with telementoring or direct mentoring.
MATERIALS AND METHODS Telementoring System A secure network was established between the mentor’s institution (Kobe University) and Seirei Mikatahara General Hospital (230.77 km from Kobe University). An optical fiber link-based network loop was set up, and a virtual private network was used as a secure link, using the 256-bit advanced encryption standard.4 The data transfer rate of this network reached 1 gigabit/s. The latency time was measured by measuring sendreturn time of the same signal at the operating room. RARP was performed with a da Vinci S surgical system (Intuitive Surgical, Sunnyvale, CA). Handwritten notes could be made on the touch-screen personal computer (SVT1511AJ; Sony, Tokyo, Japan) (Fig. 1A), and these annotations were transferred to the operating room for viewing on a monitor of the surgeon’s console with TilePro (Intuitive Surgical; Fig. 1B). Videos of the operating field were sent in high-definition serial digital interface format and were projected on 3-dimensional (3D) monitors for the remote mentor and assistant surgeons (Fig. 1C). For the 3D system, a 24-in LMD-2451TD (Sony, Tokyo, Japan) and 46-in GD-463D10 (JVC, Yokohama, Japan) display were used. Side-by-side video signals were converted to line-by-line format using a 3D signal processor SJ-3D10 (Skyjet, Kobe, Japan) and were viewed through polarizing glasses. The resolution of the 3D operating field, operating 0090-4295/14/$36.00 http://dx.doi.org/10.1016/j.urology.2014.01.010
>200 open radical prostatectomies and had completed training for the da Vinci provided by the manufacturer; thus, the experience of each surgeon was similar. After receiving Institutional Review Board approval at each institution, we prospectively collected data on the initial 30 RARP cases of each surgeon. Sixty consecutive RARP procedures were performed at Seirei Mikatahara General Hospital with telementoring, whereas 60 consecutive procedures were performed at Kobe University Hospital with direct mentoring. Thus, 2 pairs of surgeons were tested for each mentoring group. Informed consent was obtained from the patients regarding the role of the telementor. Surgical procedures of RARP were performed as described previously.6 The operating technique, ports, and suturing methods were similar between the 2 surgeons. Surgical assistants were fixed throughout the study period. In this series, Foley catheter drainage was done for 7 days, and continence was defined as no use of pads. The same pathologist examined pathologic findings throughout the study period. The remote mentor had experience with >300 robot-assisted urologic surgeries, and the mentor’s role was defined by the institutional credentialing committee in advance. The remote mentor was not expected to intervene in case of intraoperative necessity. Instead, another mentor was on standby to ensure the patient safety at the remote hospital for initial 10 cases, but the backup mentor was not allowed to intervene except in an emergency. In the present study, the local mentor only gave verbal instructions and advice and did not perform surgery using the console in the direct mentoring group. Statistical analysis was performed with Student t test and the Mann-Whitney U test for comparison of numerical variables or the chi-square test and Fisher exact test for comparison of categorical variables using JMP 10.0 software (SAS Institute Inc., Cary, NC). A probability value
RESULTS
CONCLUSION
To develop a Web-based audiovisual telementoring system for robot-assisted radical prostatectomy (RARP) and to assess the utility of this system. A telementoring system for RARP, consisting of a 3-dimensional high-definition view of the operating field, overview of the operating room, annotation function, and 2-channel audio feed with bidirectional connectivity between 2 institutions, was developed. The outcome of RARP performed for the initial 30 patients by 2 surgeons with telementoring was compared with that for 2 surgeons who received direct mentoring. This system was shown to function properly with an acceptable latency. There were no significant differences in several parameters reflecting surgical outcomes, including the operating time, complication rate, early continence status, and positive margin rate between the telementoring and direct mentoring groups. These findings suggest the usefulness of the telementoring system for promoting the spread of precise surgical techniques associated with RARP. To our knowledge, this is the first report concerning telementoring for robot-assisted surgery. UROLOGY 83: 1088e1092, 2014. 2014 Elsevier Inc.
B
ecause the learning curve for robot-assisted radical prostatectomy (RARP) has been reported to influence oncological and functional outcomes,1,2 mentoring of trainee surgeons has become more important to ensure that they attain sufficient skill without compromising the safety of their initial patients. Mentoring is usually done face-to-face, which presents practical difficulties when the mentor and trainee belong to different institutions. Advances in technology have opened new avenues for long-distance communication through telemedicine. Using such technology, an expert surgeon can observe and actively supervise a procedure performed by a trainee surgeon at another institution. Telementoring is an application of telemedicine that involves the remote guidance of procedures when the operator has limited experience with the technique.3 We constructed a telementoring system for RARP and validated its feasibility. We also examined whether the initial outcomes of RARP
Financial Disclosure: The authors declare that they have no relevant financial interests. From the Department of Urology, Kobe University Graduate School of Medicine, Kobe, Japan; and the Division of Urology, Seirei Mikatahara General Hospital, Hamamatsu, Japan Reprint requests: Nobuyuki Hinata, M.D., Ph.D., Department of Urology, Kobe University Graduate School of Medicine, 7-5-1, Kusunoki-cho, Kobe 650-0017, Japan. E-mail: [email protected] Submitted: August 22, 2013, accepted (with revisions): January 2, 2014
1088
ª 2014 Elsevier Inc. All Rights Reserved
performed by trainee surgeons were similar with telementoring or direct mentoring.
MATERIALS AND METHODS Telementoring System A secure network was established between the mentor’s institution (Kobe University) and Seirei Mikatahara General Hospital (230.77 km from Kobe University). An optical fiber link-based network loop was set up, and a virtual private network was used as a secure link, using the 256-bit advanced encryption standard.4 The data transfer rate of this network reached 1 gigabit/s. The latency time was measured by measuring sendreturn time of the same signal at the operating room. RARP was performed with a da Vinci S surgical system (Intuitive Surgical, Sunnyvale, CA). Handwritten notes could be made on the touch-screen personal computer (SVT1511AJ; Sony, Tokyo, Japan) (Fig. 1A), and these annotations were transferred to the operating room for viewing on a monitor of the surgeon’s console with TilePro (Intuitive Surgical; Fig. 1B). Videos of the operating field were sent in high-definition serial digital interface format and were projected on 3-dimensional (3D) monitors for the remote mentor and assistant surgeons (Fig. 1C). For the 3D system, a 24-in LMD-2451TD (Sony, Tokyo, Japan) and 46-in GD-463D10 (JVC, Yokohama, Japan) display were used. Side-by-side video signals were converted to line-by-line format using a 3D signal processor SJ-3D10 (Skyjet, Kobe, Japan) and were viewed through polarizing glasses. The resolution of the 3D operating field, operating 0090-4295/14/$36.00 http://dx.doi.org/10.1016/j.urology.2014.01.010
>200 open radical prostatectomies and had completed training for the da Vinci provided by the manufacturer; thus, the experience of each surgeon was similar. After receiving Institutional Review Board approval at each institution, we prospectively collected data on the initial 30 RARP cases of each surgeon. Sixty consecutive RARP procedures were performed at Seirei Mikatahara General Hospital with telementoring, whereas 60 consecutive procedures were performed at Kobe University Hospital with direct mentoring. Thus, 2 pairs of surgeons were tested for each mentoring group. Informed consent was obtained from the patients regarding the role of the telementor. Surgical procedures of RARP were performed as described previously.6 The operating technique, ports, and suturing methods were similar between the 2 surgeons. Surgical assistants were fixed throughout the study period. In this series, Foley catheter drainage was done for 7 days, and continence was defined as no use of pads. The same pathologist examined pathologic findings throughout the study period. The remote mentor had experience with >300 robot-assisted urologic surgeries, and the mentor’s role was defined by the institutional credentialing committee in advance. The remote mentor was not expected to intervene in case of intraoperative necessity. Instead, another mentor was on standby to ensure the patient safety at the remote hospital for initial 10 cases, but the backup mentor was not allowed to intervene except in an emergency. In the present study, the local mentor only gave verbal instructions and advice and did not perform surgery using the console in the direct mentoring group. Statistical analysis was performed with Student t test and the Mann-Whitney U test for comparison of numerical variables or the chi-square test and Fisher exact test for comparison of categorical variables using JMP 10.0 software (SAS Institute Inc., Cary, NC). A probability value
