Objectives: Radical cystectomy (RC) represents the gold standard treatment for high-risk bladder cancer. Despite evidence suggesting that surgical experience correlates with perioperative and... Show moreObjectives: Radical cystectomy (RC) represents the gold standard treatment for high-risk bladder cancer. Despite evidence suggesting that surgical experience correlates with perioperative and oncologic outcomes of robot-assisted RC (RARC), validated tools to assess its quality objectively are lacking. We aimed to evaluate the impact of RC-Pentafecta (absence of early major complications, absence of urinary diversion related sequelae at <= 12 months, absence of soft tissue surgical margins, >= 16 lymph nodes at final pathology and absence of clinical recurrence at <= 12 months) on oncological outcomes and the role of surgical experience on its achievement. Materials and methods: We retrospectively evaluated 366 patients undergoing RARC with intracorporeal urinary diversion in a single tertiary centre with a minimum of 1 year follow-up. Surgeries were performed using the DaVinci Xi system according to a previously described technique. Kaplan-Meier curves were used to investigate 5-years overall survival and cancer specific mortality-free survival (CSS) according to RC-Pentafecta achievement. Multivariable Cox's regressions were performed to evaluate the impact of RC-Pentafecta on overall mortality. Multivariable logistic regressions were performed to explore the effect of surgical experience on RC-pentafecta achievement. Locally weighted scatterplot smoother function was used to graphically explore this relationship. Results: Patients achieving RC-Pentafecta showed higher 5-year overall survival (71.8% vs. 59.6%, P < 0.001) and CSS (84% vs. 71%, P < 0.001) when compared with patients not achieving it. At multivariable Cox's regression, RC-Pentafecta achievement (HR 0.57, P = 0.03), positive surgical margins (HR 2.48, P = 0.002), pN+ (HR 2.23, P = 0.002), pT >= 3 (HR 1.71, P = 0.04) and current smoking status (HR 2.4, P = 0.006) were significant predictors of overall mortality. At multivariable logistic regression surgical experience (OR 1.2, P < 0.001), age (OR 0.93, P = 0.04), previous prostate surgery (OR 0.7, P = 0.02) and pT >= 3 (OR 0.8, P = 0.03) were independent predictors of RC-Pentafecta achievement. A linear relationship between surgical experience and RC-Pentafecta achievement, without reaching a plateau, was observed. Conclusions: RC-Pentafecta is a valuable tool to assess surgical quality of RARC and the experience of the center where the surgery is performed and may be used to identify "referral" centers for treatment of high-risk bladder cancer. (c) 2022 Elsevier Inc. All rights reserved. Show less
Woude, L. van der; Wouters, M.W.J.M.; Hartemink, K.J.; Heineman, D.J.; Verhagen, A.F.T.M. 2021
Objective: In patients with NSCLC, lymph node metastases are an important prognostic factor. Despite an accurate pre-operative work up, for optimal staging an intrapulmonary-and mediastinal lymph... Show moreObjective: In patients with NSCLC, lymph node metastases are an important prognostic factor. Despite an accurate pre-operative work up, for optimal staging an intrapulmonary-and mediastinal lymph node dissection (LND) as part of the operation is mandatory. The aim of this study is to assess the completeness of LND in patients undergoing an intended curative resection for NSCLC in the Netherlands and to compare performance between open surgery and minimally invasive surgery (MIS).Materials and methods: The intraoperative LND was evaluated in 7460 patients who had undergone a lobectomy for clinically staged N0-1 NSCLC (2013-2018). The LND was considered complete, when three mediastinal (N2) lymph node stations, including station 7, were sampled or dissected, in addition to the lymph nodes from station 10 and 11. A comparison was made between open surgery and MIS.Results: Of 5154 patients, who had MIS, a sufficient intrapulmonary LND was performed in 47.9% and a sufficient mediastinal LND in 58.6%. A complete LND was performed in 31.6%. For 2306 patients who had an open resection, these numbers were 45.0%, 59.0%, and 30.6%, respectively. The overall between hospital variation in a complete LND ranged between 0 and 72.5%.Conclusion: In the Netherlands, a complete LND of both intrapulmonary-and mediastinal lymph nodes is performed only in a minority of patients with clinically staged N0-1 NSCLC, with substantial between hospital variation. No differences were seen between open surgery and MIS. Because of poor performance, completeness of lymph node dissection will be recorded as a mandatory performance indicator in our national audit, to improve the quality of resection.(c) 2020 Elsevier Ltd, BASO The Association for Cancer Surgery, and the European Society of Surgical Oncology. All rights reserved. Show less
With advancement of techniques in endourology, treatments for renal stones have increased possibilities. This thesis analyses existing surgical treatments, pain treatments and renal anatomy.
The aim of the thesis was to identify clinically relevant topics within the field of minimally invasive gynecology and to formulate best practices for them.
In the current project, our main focus was to test the effectiveness of different training interventions and their impact on skill acquisition and long-term retention of laparoscopic motor skills.... Show moreIn the current project, our main focus was to test the effectiveness of different training interventions and their impact on skill acquisition and long-term retention of laparoscopic motor skills. Based on the research in this dissertation and the existing literature, I recommend instructors to design training with predetermined proficiency targets, patient-oriented (adaptive) feedback on a spaced schedule with intervals of a week instead of smaller time frames. Instructors may experiment with larger spacing intervals, but more research is needed to determine the effectiveness of more time in between training sessions. I urge instructors to be cautious in increasing training variability in training novices, since laparoscopy is an inherently complex task and can be overwhelming at the start of training. Fractionation of training of the different facets of laparoscopic surgery may be fine initially, but training focused on skill integration is desirable at a later stage. In examination, a dual-task setup can be used to assess the degree of automatization of the acquired skills. Trainers can implement the use of force measures as an additional metric, to ensure that trainees also learn how to handle different tissues safely. Show less
The current thesis explores the evidence base of new techniques in minimally invasive surgery. For this purpose the main objectives of this thesis are: • To present a multidisciplinary... Show moreThe current thesis explores the evidence base of new techniques in minimally invasive surgery. For this purpose the main objectives of this thesis are: • To present a multidisciplinary evidence based guideline for MIS including the main topics in laparoscopic surgery; • To identify the evidence of three new minimally invasive techniques: trocar types for laparoscopy, LESS-hysterectomy and hysteroscopic sterilization; • To evaluate the course of introduction of a new minimally invasive technique (robot-assisted surgery) and the status of the evidence; • To assess whether recent RCTs serve the clinical needs of the MIS approach. Providing the answers to these questions, this thesis provides insight in the evidence of MIS and its limitations. Therewith, it provides guidance to optimize research and evidence based implementation of MIS towards better minimally invasive surgical care. Show less
In recent years a flow of media reports about unsafe situations in operating rooms have reached the general public. Awareness of the importance of patient safety also reached politicians. The... Show moreIn recent years a flow of media reports about unsafe situations in operating rooms have reached the general public. Awareness of the importance of patient safety also reached politicians. The report by the Dutch inspectorate of health care __Risico__s minimaal invasieve chirurgie onderschat__ (Risks minimally invasive surgery underestimated) stressed that patient safety is especially at risk in Minimally Invasive Surgery. Therefore patient safety became a focus of research and quality improvement, also in minimally invasive surgery. The current thesis aimes to give insight into patient safety risk factors in minimally invasive surgery. Of all examined risk factors minimally invasive surgical skills appeared to be directly related to patient safety. Therefore special focus for training of these skills is necessary. Previous research has shown that during simulation training objective assessment of economy of movements and time is possible. However, until recently there was no way to objectively assess one of the most important surgical skills: tissue handling. The development of a force sensor has made it possible to measure interaction forces with artificial tissue. In this thesis the clinical implications of a force sensor and the need of this new technology within training of minimally invasive surgical skills is examined. Show less
Many topics in surgical skills education have been implemented without a solid scientific basis. For that reason we have tried to find this scientific basis. We have focused on training and... Show moreMany topics in surgical skills education have been implemented without a solid scientific basis. For that reason we have tried to find this scientific basis. We have focused on training and evaluation of minimally invasive surgical skills in a training setting and in practice in the operating room. This thesis has led to an enlarged insight in the organization of surgical skills training during residency training of surgical medical specialists. Show less
