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Re: Suture Techniques during Laparoscopic and Robot-Assisted Partial Nephrectomy

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Letter to the Editor

Suture Techniques during Laparoscopic and Robot-Assisted Partial Nephrectomy: A Systematic Review and Quantitative Synthesis of Peri-Operative Outcomes

Dear Sir,

We would like to congratulate the authors of this systematic review [1] highlighting the evolution of suture techniques for partial nephrectomy in the era of minimally invasive surgery. The authors note the “significant technical modification” for the replacement of intracorporeal free-hand knot tying with a sliding clip technique [2]. This technique has revolutionised the practice of PN and reduced the risk of the “cheese cutting effect” with the conventional suturing techniques. It is worth noting that this laparoscopic technique was first described by Agarwal et al in the BJUI in 2007 [3]. Indeed one of the authors of this SR also published on the robotic application of this technique in a publication in European Urology in 2009 (2), which also was remiss in referencing the original description of the technique by Agarwal et al., published 2 years prior.

This oversight aside, the authors should be commended for helping to frame the evolution of surgical techniques across minimally invasive approaches over time, with the ultimate goal of complete tumour excision, minimal complications and maximal functional preservation, since we’re using more technology now a days for advance study of medicine, like robots or CT scanners, although the cost of these CT scanners could be high, the value is worthy because they help a lot in the medicine area. While this paper’s title suggests a focus on suture techniques during surgery the authors concluding remarks do not address this focus. We believe suturing techniques will continue to evolve, and that there will be further technological, and technical innovation that will further improve outcomes for patients and will make more meaningful additions to the published literature in this field.

Brian D Kelly, Christophe Orye, Homi Zargar, Anthony J Costello and Dinesh Agarwal

Correspondence: Dinesh Agarwal, Urology Unit, Level 3 Centre, Infill Building, The Royal Melbourne Hospital, City Campus, Grattan Street, Parkville 3050 Victoria, Australia.
e-mail: [email protected]

 

References

  1. Bertolo, Riccardo et al. Suture Techniques during Laparoscopic and Robot-Assisted Partial Nephrectomy: A Systematic Review and Quantitative Synthesis of Peri-Operative Outcomes. BJU Int 2018;  123:923-46 doi:https://dx.doi.org/10.1111/bju.14537.
  2. Benway, Brian M et al. Robotic Partial Nephrectomy with Sliding-Clip Renorrhaphy: Technique and Outcomes. Eur Urol 2009; 55:592-9 doi:10.1016/j.eururo.2008.12.028.
  3. Agarwal, Dinesh et al. Modified Technique of Renal Defect Closure Following Laparoscopic Partial Nephrectomy. BJU Int 2007; 100:967-70 doi:10.1111/j.1464-410x.2007.07104.x.
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Article of the week: Suture techniques during laparoscopic and robot‐assisted partial nephrectomy

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Every week, the Editor-in-Chief selects an Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is a video produced by the authors. Please use the tools at the bottom of the post if you would like to make a comment. 

If you only have time to read one article this week, it should be this one.

Suture techniques during laparoscopic and robot‐assisted partial nephrectomy: a systematic review and quantitative synthesis of peri‐operative outcomes

Riccardo Bertolo*, Riccardo Campi†, Tobias Klatte‡, Maximilian C. Kriegmair§, Maria Carmen Mir, Idir Ouzaid**, Maciej Salagierski††, Sam Bhayani‡‡, Inderbir Gill§§¶¶, Jihad Kaouk* and Umberto Capitanio‡‡§§***††† On behalf of the Young Academic Urologists (YAU) Kidney Cancer working group of the European Urological Association (EAU)

 

*Department of Urology, Cleveland Clinic Foundation, Cleveland, OH, USA, †Department of Urology, University of Florence, Florence, Italy, ‡Department of Urology, Royal Bournemouth and Christchurch Hospitals, Bournemouth, UK, §Department of Urology, University Medical Centre Mannheim, Mannheim, Germany, Department of Urology, Fundación Instituto Valenciano de Oncología, Valencia, Spain, **Department of Urology, Bichat Hospital, APHP, Paris Diderot University, Paris, France, ††Urology Department, Faculty of Medicine and Health Sciences, University of Zielona Góra, Zielona Góra, Poland, ‡‡Division of Urology, Washington University School of Medicine, St Louis, MO, §§Keck School of Medicine, USC Institute of Urology, ¶¶Catherine and Joseph Aresty Department of Urology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA, ***Department of Urology, San Raffaele Scientific Institute, and †††Division of Experimental Oncology/Unit of Urology, URI, IRCCS San Raffaele Hospital, Milan, Italy

 

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Abstract

Objective

To summarize the available evidence on renorrhaphy techniques and to assess their impact on peri‐operative outcomes after minimally invasive partial nephrectomy (MIPN).

Materials and Methods

A systematic review of the literature was performed in January 2018 without time restrictions, using MEDLINE, Cochrane and Web of Science databases according to the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses statement recommendations. Studies providing sufficient details on renorrhaphy techniques during laparoscopic or robot‐assisted partial nephrectomy and comparative studies focused on peri‐operative outcomes were included in qualitative and quantitative analyses, respectively.

Fig. 4. Integrated overview of evidence‐based technical principles for renal reconstruction during minimally invasive partial nephrectomy and suggested standardized reporting of key renorrhaphy features in clinical studies on this topic.

Results

Overall, 67 and 19 studies were included in the qualitative and quantitative analyses, respectively. The overall quality of evidence was low. Specific tumour features (i.e. size, hilar location, anatomical complexity, nearness to renal sinus and/or urinary collecting system), surgeon’s experience, robot‐assisted technology, as well as the aim of reducing warm ischaemia time and the amount of devascularized renal parenchyma preserved represented the key factors driving the evolution of the renorrhaphy techniques during MIPN over the past decade. Quantitative synthesis showed that running suture was associated with shorter operating and ischaemia time, and lower postoperative complication and transfusion rates than interrupted suture. Barbed suture had lower operating and ischaemia time and less blood loss than non‐barbed suture. The single‐layer suture technique was associated with shorter operating and ischaemia time than the double‐layer technique. No comparisons were possible concerning renal functional outcomes because of non‐homogeneous data reporting.

Conclusions

Renorrhaphy techniques significantly evolved over the years, improving outcomes. Running suture, particularly using barbed wires, shortened the operating and ischaemia times. A further advantage could derive from avoiding a double‐layer suture.

 

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Video: Suture techniques during laparoscopic and robot‐assisted partial nephrectomy

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Suture techniques during laparoscopic and robot‐assisted partial nephrectomy: a systematic review and quantitative synthesis of peri‐operative outcomes

by Riccardo Bertolo (@RicBertolo)

Read the full article

Abstract

Objective

To summarize the available evidence on renorrhaphy techniques and to assess their impact on peri‐operative outcomes after minimally invasive partial nephrectomy (MIPN).

Materials and Methods

A systematic review of the literature was performed in January 2018 without time restrictions, using MEDLINE, Cochrane and Web of Science databases according to the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses statement recommendations. Studies providing sufficient details on renorrhaphy techniques during laparoscopic or robot‐assisted partial nephrectomy and comparative studies focused on peri‐operative outcomes were included in qualitative and quantitative analyses, respectively.

Results

Overall, 67 and 19 studies were included in the qualitative and quantitative analyses, respectively. The overall quality of evidence was low. Specific tumour features (i.e. size, hilar location, anatomical complexity, nearness to renal sinus and/or urinary collecting system), surgeon’s experience, robot‐assisted technology, as well as the aim of reducing warm ischaemia time and the amount of devascularized renal parenchyma preserved represented the key factors driving the evolution of the renorrhaphy techniques during MIPN over the past decade. Quantitative synthesis showed that running suture was associated with shorter operating and ischaemia time, and lower postoperative complication and transfusion rates than interrupted suture. Barbed suture had lower operating and ischaemia time and less blood loss than non‐barbed suture. The single‐layer suture technique was associated with shorter operating and ischaemia time than the double‐layer technique. No comparisons were possible concerning renal functional outcomes because of non‐homogeneous data reporting.

Conclusions

Renorrhaphy techniques significantly evolved over the years, improving outcomes. Running suture, particularly using barbed wires, shortened the operating and ischaemia times. A further advantage could derive from avoiding a double‐layer suture.

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Article of the Week: An assessment of the physical impact of complex surgical tasks on surgeon errors and discomfort

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Every week the Editor-in-Chief selects the Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an accompanying editorial written by a prominent member of the urological community. This blog is intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation.

If you only have time to read one article this week, it should be this one.

An assessment of the physical impact of complex surgical tasks on surgeon errors and discomfort: a comparison between robot-assisted, laparoscopic and open approaches

Oussama Elhage*†, Ben Challacombe*, Adam Shortland‡ and Prokar Dasgupta*
§*The Urology Centre, Guy’s and St Thomas’ NHS Foundation Trust, †Medical Research Council (MRC) Centre for Transplantation, King’s College London, ‡One Small Step Laboratory, and §MRC Centre for Transplantation & National Institute for Health Research (NIHR) comprehensive Biomedical Research Centre, King’s College London, King’s Health Partners, Guy’s Hospital, London, UK

 

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OBJECTIVES

To evaluate, in a simulated suturing task, individual surgeons’ performance using three surgical approaches: open, laparoscopic and robot-assisted.

SUBJECTS AND METHODS

Six urological surgeons made an in vitro simulated vesico-urethral anastomosis. All surgeons performed the simulated suturing task using all three surgical approaches (open, laparoscopic and robot-assisted). The time taken to perform each task was recorded. Participants were evaluated for perceived discomfort using the self-reporting Borg scale. Errors made by surgeons were quantified by studying the video recording of the tasks. Anastomosis quality was quantified using scores for knot security, symmetry of suture, position of suture and apposition of anastomosis.

RESULTS

The time taken to complete the task by the laparoscopic approach was on average 221 s, compared with 55 s for the open approach and 116 s for the robot-assisted approach (anova, P < 0.005). The number of errors and the level of self-reported discomfort were highest for the laparoscopic approach (anova, P < 0.005). Limitations of the present study include the small sample size and variation in prior surgical experience of the participants.

CONCLUSIONS

In an in vitro model of anastomosis surgery, robot-assisted surgery combines the accuracy of open surgery while causing lesser surgeon discomfort than laparoscopy and maintaining minimal access.

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Editorial: Conventional laparoscopic surgery – more pain, no gain!

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Advances in surgical technology have revolutionized the way surgery is performed today. Conventional laparoscopic surgery dominated the surgical paradigm for several decades, until robot-assisted surgery created the next giant leap. In the pressent article, Elhage et al. [1] compare and correlate physical stress and surgical performances among three modes of a standardized surgical step. Their study shows the obvious physical strain and technical limitations faced while performing conventional laparoscopic surgery, subsequently leading to compromised surgical outcomes. The physical impact of conventional laparoscopic surgery has been well documented through surgeon feedback as well as ergonomic assessment [2, 3]. Various studies have reported that higher physical stress, associated with ergonomic limitations, is experienced when performing conventional laparoscopy compared to the comfort and ease of robot-assisted surgery, as highlighted in the present study. Increased workload has also been associated with performance errors, with a steep learning curve needed to achieve surgical excellence during conventional laparoscopy [4].

Currently, the use of robot-assisted surgery is on the rise, as an alternative to both open and conventional laparoscopic surgery across the developed world, despite its obvious economic limitations. Better ergonomics during robot-assisted surgery will increase the comfort of the surgeon, but the future of surgery may easily be linked to the improvements experienced by all of us in the automobile industry. Developments, from manual gear-clutch control to automatic speed control and the luxury of adaptive cruise control today, make us safe drivers with minimal physical stress. The concept of adaptive cruise control, which adjusts the speed of a vehicle in relation to its surroundings, sounds similar to the leap from manual camera control during conventional laparoscopy to console-based control during camera navigation in robot-assisted surgery. With advances in the speed and size of computers, pneumatic-based joint mechanics and mindfulness meditation on the horizon, it will not be long before surgeons will sit back and watch the marvel of the machine. Surgeons just need to learn to hold on to their seats!

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Syed J. Raza*, Khurshid A. Guru† and Robert P. Huben†
*Fellow, †Endowed Professor of Urologic Oncology, Department of Urology and A.T.L.A.S (Applied Technology Laboratory for Advanced Surgery) Program, Roswell Park Cancer Institute, Buffalo, NY, USA

 

References

 

1 Elhage O, Challacombe B, Shortland A, Dasgupta P. An assessment of the physical impact of complex surgical tasks on surgeon errors and discomfort: a comparison among robot-assisted, laparoscopic and open approaches. BJU Int 2015; 115: 274–281

2 Plerhoples TA, Hernandez-Boussard T, Wren SM. The aching surgeon: a survey of physical discomfort and symptoms following open, laparoscopic and robotic surgery.

J Robotic Surg 2012; 6: 65–723 Hubert N, Gilles M, Desbrosses K, Meyer JP, Felblinger J, Hubert J. Ergonomic assessment of the surgeon’s physical workload during standard and robotic assisted laparoscopic procedures. Int J Med Robot 2013; 9:142–147

4 Yurko YY, Scerbo MW, Prabhu AS, Acker CE, Stefanidis D. Higher mental workload is associated with poorer laparoscopic performance as measured by the NASA-TLX tool. Simul Healthc 2010; 5: 267–271

 

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