- Email: [email protected]
MP20-16 TRAINING AND SKILLS ASSESSMENT FOR FUSION-GUIDED PROSTATE BIOPSY: DEFINING THE LEARNING CURVE
Vol. 195, No. 4S, Supplement, Friday, May 6, 2016
10 fold magnification provide surgeons improved anatomical vision and more precise instrument control compared to open or laparoscopic techniques. However, the potential benefits of robotic techniques may have tradeoffs in increased mental and physical demands for the surgeons. The assisting surgeon, also has the added workload of maintaining working postures that do not impede the robotic arms. This study implemented an innovative motion tracking tool along with validated workload questionnaires to assess the ergonomics and workload for both assisting and console surgeons during robotic surgery. METHODS: Ten individual surgeons (6 console surgeons and 4 assistant surgeons) performed 15 robotic prostatectomy cases while wearing inertia measurement units (IMUs) to track neck, shoulder, and torso motion during each case. Postoperatively, participants completed a validated workload questionnaire (NASA-TLX). Analysis of variance was performed on all response variables that do not violate the assumption of normality to identify the impact of surgeon role (Console vs. Assistant). RESULTS: Twenty-six questionnaires were completed from 13 assisting and 13 console surgeons over the 15 cases. Self-reported mental demand was 41% higher for surgeons at the console than assisting (p<0.05), but physical demand was not statistically different. Post-operative pain was reported highest for the right shoulder and neck and this was more frequently seen in the console surgeons. On IMU readings, the assisting surgeon experienced high neck flexion (>10 degrees) duration over 42% of the procedure compared to only 24% in the console surgeon. In general, surgeons posture on the console was primarily static resulting in fewer movements compared to assisting surgeons. Table 1 summarizes posture movements and durations of static postures. CONCLUSIONS: Postures were more ergonomic during console tasks than assisting by the operating table. However, the console constrains postures leading to static postural loads that have been associated with musculoskeletal symptoms for the neck, torso and shoulders.
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We aim to define the differences among users with varying levels of experience with a tracked fusion biopsy platform. METHODS: 10 users within 5 different experience levels were asked to perform electromagnetically tracked FBx after completion of a standardized didactic and hands-on course. Experience levels included gold standard (>1000 FBx), Expert (50-100 FBx), urologists, radiology residents, and medical students without FBx experience. A prostate phantom model (CIRS Inc.) with 4 gold fiducial targets was segmented on T2 imaging. FBx of each target was performed using rigid registration with the UroNav system (Invivo Corp.) and then with ultrasound (US) only. Mechanical targeting error (MTE) was calculated as distance between the bullseye target and actual core location during FBx; fusion registration error (FRE) was the distance between MR target and transformed core location from the US only biopsy. Time to completion of each task during FBx was recorded. RESULTS: Data from the initial trial for each user among experience levels is reported. Mean overall time to completion of FBx by the different experience level subgroups ranged from 13:14 to 37:42 [Figure 1a]. Range of mean MTE, a measure of ability to visualize and biopsy the target, was 0.79 mm-1.42 mm and did not correlate with user level (p¼0.893) Mean FRE ranged from 3.03 mm in the gold standard group up to 6.12 mm in the medical student group. FRE demonstrated a linear relationship with user level and was significantly correlated (correlation coefficient 0.935, p<0.001) [Figure 1b]. CONCLUSIONS: Fusion-guided biopsy is an acquired skillset with sufficient experience needed to provide an accurate sampling within a reasonable time. Characterization of the learning curve by experience level may help determine a standardized level of proficiency and core competencies for this new procedure, prior to employing it in clinical practice.
Source of Funding: None
MP20-16 TRAINING AND SKILLS ASSESSMENT FOR FUSION-GUIDED PROSTATE BIOPSY: DEFINING THE LEARNING CURVE Akhil Muthigi*, Arvin George, Daniel Su, Bethesda, MD; Pingkun Yan, Jochen Kruecker, Cambridge, MA; Harish Narayanan, Janice Thai, Bethesda, MD; Meet Kadakia, Michael Kongnyuy, Amogh Iyer, Abhinav Sidana, Amichai Kilchevsky, Thomas Frye, Baris Turkbey, Peter Choyke, Bethesda, MD; Bradford Wood, Bethesda, MD; Peter Pinto, Bethesda, MD INTRODUCTION AND OBJECTIVES: Advances in multiparametric MRI combined with improved sampling by MR/TRUS fusionguided prostate biopsy (FBx) have resulted in rapid adoption of this novel technology into the biopsy paradigm. FBx accuracy is dependent on a number of factors and acquired skills that vary by user experience.
Source of Funding: This research was supported by the Intramural Research Program of the National Institutes of Health (NIH), National Cancer Institute, Center for Cancer Research, and the Center for Interventional Oncology. NIH and Philips Healthcare have a cooperative research and development agreement. NIH and Philips share intellectual property in the field. This research was also made possible through the National Institutes of Health Medical Research Scholars Program, a public-private partnership supported jointly by the NIH and
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generous contributions to the Foundation for the NIH from Pfizer Inc., The Doris Duke Charitable Foundation, The Alexandria Real Estate Equities, Inc. and Mr. and Mrs. Joel S. Marcus, and the Howard Hughes Medical Institute, as well as other private donors. For a complete list, please visit the Foundation website at: http://fnih.org/work/education-training0/medical-research-scholars-program
MP20-17 ACCELEROMETER MEASUREMENT OF HEAD MOVEMENT DURING LAPAROSCOPIC SURGERY: WILL IT HELP OPTIMIZE ERGONOMICS OF SURGERY? Sarayuth Viriyasiripong, Asis Lopez, Weil Lai*, Gregory Mitchell, Sree Harsha Mandava, Aaron Boonjindasup, Mary Powers, Jonathan Silberstein, Benjamin Lee, New Orleans, LA INTRODUCTION AND OBJECTIVES: To detect and measure surgeon head motion during laparoscopic simulator performance to determine whether expert surgeons have higher economy of motion in head movement, including change of direction, compared to intermediate and novice surgeons. We investigated head movement as an objective tool for the assessment of laparoscopic surgical skills and its potential use for assessing novice surgeons’ progress on the learning curve. METHODS: After obtaining institutional review board approval, medical students (n¼6), urology residents (n¼9), and attending staff surgeons (n¼4) from one academic institution were recruited. Participants were grouped by level of experience and performed tasks on the EDGE laparoscopic simulator. Surgeons wore a commercially available wireless EEG monitor, as a flexible, adjustable, lightweight headband with 7 sensors: 2 forehead sensors, 2 ear sensors, and 3 reference sensors. The headband incorporates a 3-axis accelerometer, enabling quantification of head movements. A variance analysis was used to compare the average head movement acceleration data among the groups. RESULTS: Analysis of the average acceleration rate of head movement showed significant differences among groups on both the vertical and horizontal axes (p¼0.006 and 0.018) in the laparoscopic suturing task, demonstrating the ability to distinguish between experts and novices (Table 1). The average acceleration among groups trended towards significance on the vertical and horizontal axes (p¼0.078 and 0.077) in the peg transfer task. The analysis of the forward-backward axis showed no significant differences among the groups. CONCLUSIONS: Accelerometer-based motion analysis of head movement appears to be a useful tool to evaluate laparoscopic skill development of surgeons in terms of their economy of motion and could potentially be used for ergonomic assessment of training in the future.
Vol. 195, No. 4S, Supplement, Friday, May 6, 2016
MP20-18 CONCURRENT VALIDITY OF A SIMULATED INANIMATE MODEL FOR PHYSICAL LEARNING EXPERIENCE IN PARTIAL NEPHRECTOMY (SIMPLE-PN) Braden Candela*, Jonathan Stone, Jennifer Park, Guan Wu, Hani Rashid, Jean Joseph, Ahmed Ghazi, Rochester, NY INTRODUCTION AND OBJECTIVES: The implementation of surgical simulators as training & assessment tools requires extensive validation. We previously demonstrated face (realism), content (usefulness for training) & construct validity (differentiating novice & expert performance) of our simulated inanimate model for robot assisted partial nephrectomy (RAPN). In line with most robotic surgery simulators, concurrent validity (the extent to which the results generated from the simulator correlate with the gold standard) & predictive validity (extent to which an assessment will predict future performance) remain sparse. This is mainly due to complicated conversion algorithms required to compare objective, motion-based assessment metrics generated from simulators to subjective assessment of live surgical performance. From design to conception, we focused on the ability of our models to reproduce procedure specific performance metrics. We present the concurrent validity of SIMPLE-PN through a direct comparison of objective operative metrics from both simulated & live RAPN performance. METHODS: A total of 8 robotic urologists (4 experts & 4 novice with > & < 250 upper tract robotic cases) performed all steps of a RAPN on the previously validated inanimate model. Live cases performed by the same urologists, with analogous nephrometry scores were identified over the preceding 6 months. Procedure-specific operative metrics (warm ischemia time-WIT, positive margins, urinary leak & estimated blood loss-EBL) recorded from both simulated & live cases were compared using paired t-tests. RESULTS: No significant differences were found between the simulation & real cases for WIT (p¼0.09, EBL (p¼0.2), positive margins (p¼0.2) or urinary leak (p¼0.35). The lack of difference for operative performance still held true when comparing experts & novice groups separately. The largest difference was found for WIT followed by EBL & trended towards SIMPLE-PN being more difficult (table 1). CONCLUSIONS: This study shows no difference between operative performance on real & simulated surgeries, thereby establishing the concurrent validity of SIMPLE-PN. This is the first report utilizing procedure-specific operative metrics for assessment of live surgery to objectively demonstrate concurrent validity of a training model
Source of Funding: none
MP20-19 SHARED DISCUSSION OR SELF-PROMOTION? USE OF TWITTER BY U.S. UROLOGY RESIDENCY PROGRAMS Kevin Koo*, E. Ann Gormley, Lebanon, NH
Source of Funding: None
INTRODUCTION AND OBJECTIVES: Social media use by urological organizations is increasing. Twitter has become a popular means of disseminating research findings and communicating at conferences. Engagement on Twitter by academic urology programs is now emerging, but its use and impact are less well characterized. METHODS: Twitter was queried with the names of all U.S. allopathic urology training programs and directors. Accounts not belonging specifically to the program or department, or that had not ever
10 fold magnification provide surgeons improved anatomical vision and more precise instrument control compared to open or laparoscopic techniques. However, the potential benefits of robotic techniques may have tradeoffs in increased mental and physical demands for the surgeons. The assisting surgeon, also has the added workload of maintaining working postures that do not impede the robotic arms. This study implemented an innovative motion tracking tool along with validated workload questionnaires to assess the ergonomics and workload for both assisting and console surgeons during robotic surgery. METHODS: Ten individual surgeons (6 console surgeons and 4 assistant surgeons) performed 15 robotic prostatectomy cases while wearing inertia measurement units (IMUs) to track neck, shoulder, and torso motion during each case. Postoperatively, participants completed a validated workload questionnaire (NASA-TLX). Analysis of variance was performed on all response variables that do not violate the assumption of normality to identify the impact of surgeon role (Console vs. Assistant). RESULTS: Twenty-six questionnaires were completed from 13 assisting and 13 console surgeons over the 15 cases. Self-reported mental demand was 41% higher for surgeons at the console than assisting (p<0.05), but physical demand was not statistically different. Post-operative pain was reported highest for the right shoulder and neck and this was more frequently seen in the console surgeons. On IMU readings, the assisting surgeon experienced high neck flexion (>10 degrees) duration over 42% of the procedure compared to only 24% in the console surgeon. In general, surgeons posture on the console was primarily static resulting in fewer movements compared to assisting surgeons. Table 1 summarizes posture movements and durations of static postures. CONCLUSIONS: Postures were more ergonomic during console tasks than assisting by the operating table. However, the console constrains postures leading to static postural loads that have been associated with musculoskeletal symptoms for the neck, torso and shoulders.
THE JOURNAL OF UROLOGYâ
e219
We aim to define the differences among users with varying levels of experience with a tracked fusion biopsy platform. METHODS: 10 users within 5 different experience levels were asked to perform electromagnetically tracked FBx after completion of a standardized didactic and hands-on course. Experience levels included gold standard (>1000 FBx), Expert (50-100 FBx), urologists, radiology residents, and medical students without FBx experience. A prostate phantom model (CIRS Inc.) with 4 gold fiducial targets was segmented on T2 imaging. FBx of each target was performed using rigid registration with the UroNav system (Invivo Corp.) and then with ultrasound (US) only. Mechanical targeting error (MTE) was calculated as distance between the bullseye target and actual core location during FBx; fusion registration error (FRE) was the distance between MR target and transformed core location from the US only biopsy. Time to completion of each task during FBx was recorded. RESULTS: Data from the initial trial for each user among experience levels is reported. Mean overall time to completion of FBx by the different experience level subgroups ranged from 13:14 to 37:42 [Figure 1a]. Range of mean MTE, a measure of ability to visualize and biopsy the target, was 0.79 mm-1.42 mm and did not correlate with user level (p¼0.893) Mean FRE ranged from 3.03 mm in the gold standard group up to 6.12 mm in the medical student group. FRE demonstrated a linear relationship with user level and was significantly correlated (correlation coefficient 0.935, p<0.001) [Figure 1b]. CONCLUSIONS: Fusion-guided biopsy is an acquired skillset with sufficient experience needed to provide an accurate sampling within a reasonable time. Characterization of the learning curve by experience level may help determine a standardized level of proficiency and core competencies for this new procedure, prior to employing it in clinical practice.
Source of Funding: None
MP20-16 TRAINING AND SKILLS ASSESSMENT FOR FUSION-GUIDED PROSTATE BIOPSY: DEFINING THE LEARNING CURVE Akhil Muthigi*, Arvin George, Daniel Su, Bethesda, MD; Pingkun Yan, Jochen Kruecker, Cambridge, MA; Harish Narayanan, Janice Thai, Bethesda, MD; Meet Kadakia, Michael Kongnyuy, Amogh Iyer, Abhinav Sidana, Amichai Kilchevsky, Thomas Frye, Baris Turkbey, Peter Choyke, Bethesda, MD; Bradford Wood, Bethesda, MD; Peter Pinto, Bethesda, MD INTRODUCTION AND OBJECTIVES: Advances in multiparametric MRI combined with improved sampling by MR/TRUS fusionguided prostate biopsy (FBx) have resulted in rapid adoption of this novel technology into the biopsy paradigm. FBx accuracy is dependent on a number of factors and acquired skills that vary by user experience.
Source of Funding: This research was supported by the Intramural Research Program of the National Institutes of Health (NIH), National Cancer Institute, Center for Cancer Research, and the Center for Interventional Oncology. NIH and Philips Healthcare have a cooperative research and development agreement. NIH and Philips share intellectual property in the field. This research was also made possible through the National Institutes of Health Medical Research Scholars Program, a public-private partnership supported jointly by the NIH and
THE JOURNAL OF UROLOGYâ
e220
generous contributions to the Foundation for the NIH from Pfizer Inc., The Doris Duke Charitable Foundation, The Alexandria Real Estate Equities, Inc. and Mr. and Mrs. Joel S. Marcus, and the Howard Hughes Medical Institute, as well as other private donors. For a complete list, please visit the Foundation website at: http://fnih.org/work/education-training0/medical-research-scholars-program
MP20-17 ACCELEROMETER MEASUREMENT OF HEAD MOVEMENT DURING LAPAROSCOPIC SURGERY: WILL IT HELP OPTIMIZE ERGONOMICS OF SURGERY? Sarayuth Viriyasiripong, Asis Lopez, Weil Lai*, Gregory Mitchell, Sree Harsha Mandava, Aaron Boonjindasup, Mary Powers, Jonathan Silberstein, Benjamin Lee, New Orleans, LA INTRODUCTION AND OBJECTIVES: To detect and measure surgeon head motion during laparoscopic simulator performance to determine whether expert surgeons have higher economy of motion in head movement, including change of direction, compared to intermediate and novice surgeons. We investigated head movement as an objective tool for the assessment of laparoscopic surgical skills and its potential use for assessing novice surgeons’ progress on the learning curve. METHODS: After obtaining institutional review board approval, medical students (n¼6), urology residents (n¼9), and attending staff surgeons (n¼4) from one academic institution were recruited. Participants were grouped by level of experience and performed tasks on the EDGE laparoscopic simulator. Surgeons wore a commercially available wireless EEG monitor, as a flexible, adjustable, lightweight headband with 7 sensors: 2 forehead sensors, 2 ear sensors, and 3 reference sensors. The headband incorporates a 3-axis accelerometer, enabling quantification of head movements. A variance analysis was used to compare the average head movement acceleration data among the groups. RESULTS: Analysis of the average acceleration rate of head movement showed significant differences among groups on both the vertical and horizontal axes (p¼0.006 and 0.018) in the laparoscopic suturing task, demonstrating the ability to distinguish between experts and novices (Table 1). The average acceleration among groups trended towards significance on the vertical and horizontal axes (p¼0.078 and 0.077) in the peg transfer task. The analysis of the forward-backward axis showed no significant differences among the groups. CONCLUSIONS: Accelerometer-based motion analysis of head movement appears to be a useful tool to evaluate laparoscopic skill development of surgeons in terms of their economy of motion and could potentially be used for ergonomic assessment of training in the future.
Vol. 195, No. 4S, Supplement, Friday, May 6, 2016
MP20-18 CONCURRENT VALIDITY OF A SIMULATED INANIMATE MODEL FOR PHYSICAL LEARNING EXPERIENCE IN PARTIAL NEPHRECTOMY (SIMPLE-PN) Braden Candela*, Jonathan Stone, Jennifer Park, Guan Wu, Hani Rashid, Jean Joseph, Ahmed Ghazi, Rochester, NY INTRODUCTION AND OBJECTIVES: The implementation of surgical simulators as training & assessment tools requires extensive validation. We previously demonstrated face (realism), content (usefulness for training) & construct validity (differentiating novice & expert performance) of our simulated inanimate model for robot assisted partial nephrectomy (RAPN). In line with most robotic surgery simulators, concurrent validity (the extent to which the results generated from the simulator correlate with the gold standard) & predictive validity (extent to which an assessment will predict future performance) remain sparse. This is mainly due to complicated conversion algorithms required to compare objective, motion-based assessment metrics generated from simulators to subjective assessment of live surgical performance. From design to conception, we focused on the ability of our models to reproduce procedure specific performance metrics. We present the concurrent validity of SIMPLE-PN through a direct comparison of objective operative metrics from both simulated & live RAPN performance. METHODS: A total of 8 robotic urologists (4 experts & 4 novice with > & < 250 upper tract robotic cases) performed all steps of a RAPN on the previously validated inanimate model. Live cases performed by the same urologists, with analogous nephrometry scores were identified over the preceding 6 months. Procedure-specific operative metrics (warm ischemia time-WIT, positive margins, urinary leak & estimated blood loss-EBL) recorded from both simulated & live cases were compared using paired t-tests. RESULTS: No significant differences were found between the simulation & real cases for WIT (p¼0.09, EBL (p¼0.2), positive margins (p¼0.2) or urinary leak (p¼0.35). The lack of difference for operative performance still held true when comparing experts & novice groups separately. The largest difference was found for WIT followed by EBL & trended towards SIMPLE-PN being more difficult (table 1). CONCLUSIONS: This study shows no difference between operative performance on real & simulated surgeries, thereby establishing the concurrent validity of SIMPLE-PN. This is the first report utilizing procedure-specific operative metrics for assessment of live surgery to objectively demonstrate concurrent validity of a training model
Source of Funding: none
MP20-19 SHARED DISCUSSION OR SELF-PROMOTION? USE OF TWITTER BY U.S. UROLOGY RESIDENCY PROGRAMS Kevin Koo*, E. Ann Gormley, Lebanon, NH
Source of Funding: None
INTRODUCTION AND OBJECTIVES: Social media use by urological organizations is increasing. Twitter has become a popular means of disseminating research findings and communicating at conferences. Engagement on Twitter by academic urology programs is now emerging, but its use and impact are less well characterized. METHODS: Twitter was queried with the names of all U.S. allopathic urology training programs and directors. Accounts not belonging specifically to the program or department, or that had not ever