Surgical benchmarks, mid-term oncological outcomes, and impact of surgical team composition on simultaneous enbloc robot-assisted radical cystectomy and nephroureterectomy

The guideline-adherent treatment of bladder and upper urinary tract malignancies implies radical cystectomy and nephroureterectomy [1, 2]. While metachronous urothelial cancer in the lower and upper urinary tract has been reported in a relevant proportion of patients initially diagnosed with urothelial cancer in the upper urinary tract [3] and to a lesser extent in patients initially diagnosed with urothelial cancer in the bladder [4], simultaneous urothelial cancer manifestation in the lower and upper urinary tract affects 2% of patients [5]. Combined lower and upper urinary tract resection is warranted in these patients. While data describing the surgical benchmarks of simultaneous enbloc robot-assisted radical cystectomy and nephro-ureterectomy [6‐11] have been reported, information on mid-term oncological outcomes is lacking.

Without the proper training of the whole surgical team (not only console surgeons), the operative duration will unavoidably be prolonged, particularly for complex procedures. A prolonged operative duration has been associated with an increased incidence of postoperative complications in laparoscopic and robotic procedures [12, 13]. In addition, a predictable operative duration is crucial for the efficient scheduling of operating room utilization, as both under- and overscheduling have major economic impacts. Among other factors, the team composition plays a relevant role in the operative duration beyond the learning curve [14‐18]. To date, the impact of the surgical team composition on the duration of enbloc robot-assisted radical cystectomy and nephro-ureterectomy, a complex, multistep procedure, has not been explored.

The aims of this manuscript were as follows: (1) to report the surgical benchmarks and postoperative complications; (2) to report mid-term oncological outcomes of simultaneous enbloc robot-assisted radical cystectomy and nephro-ureterectomy at a single centre; and (3) to assess the impact of the team composition (console surgeon vs patient-side surgeon) on the duration of this procedure.

This series of consecutive patients undergoing enbloc robot-assisted radical cystectomy and nephro-ureterectomy suggests that this complex procedure can be conducted with an acceptable operative duration and limited blood loss by an experienced robotic surgeon. Furthermore, the procedure resulted in a limited postoperative complication rate. The mid-term oncological outcomes were in line with the survival estimates for urothelial bladder cancer [21, 22]. As such, these findings support the findings from previous reports [6‐11] regarding surgical safety while adding information in terms of mid-term oncological outcomes.

With regard to the team composition, the data suggested a steep improvement in console surgeon performance (expressed as the console duration) with the progression of surgical experience after taking into account the degree of abdominal adhesions. This is in line with previous data reporting that experienced console surgeons have a steep learning curve even for technically demanding procedures, e.g., 20–30 cases for radical cystectomy [23, 24]. As such, these data seem to expand the applicability of a steep learning curve in experienced surgeons to include very rarely performed procedures.

In contrast to the console duration, the total operative duration did not decrease with increasing centre experience with this specific procedure, even after taking into account the degree of adhesions. This fact suggests that while the console surgeon improved his performance, for the patient-side part of the procedure, i.e., positioning, pneumoperitoneum, port insertion, docking and undocking, there was stagnation. We interpret this observation as the result of an ad hoc composition of the surgical team (patient-side surgeon and nurses). Indeed, while the same console surgeon performed all procedures, the patient-side surgeon and surgical nurses were assigned ad hoc from a pool of urology residents and specialized robotic surgical nurses. While exposed daily to routine robot-assisted procedures, such as prostatectomy, the rare confrontation of the team composed ad hoc with this infrequent procedure might have, in our interpretation, prevented increases in the efficiency of the surgical team as a whole and therefore might have negatively affected the total operative duration. Because the total operative duration is a crucial variable for resource utilization and for patient outcomes [12, 13], this issue is of clinical relevance. Simulation training research [25‐32] often focuses on the console surgeon, and only recently have virtual simulators integrating the console surgeon and bedside assistants become available. However, considering that a non-negligible part of the operative duration (on average, approximately 1/3 in this cohort) seems to be driven by the patient-side steps of the procedure, training including positioning and port placement/replacement and docking/undocking specific to the procedure [27] might be helpful to improve performance in terms of the total operative duration.

Previous studies have addressed the impact of the team composition regarding the experience of the patient-side assistant [33‐35] for different robot-assisted urological procedures. After adjusting for prostate size, the seniority of the bedside assistant did not affect the total operative duration in a retrospective cohort of 106 patients undergoing robot-assisted prostatectomy [33]. We consider that the divergence to our findings is the result of a very different type of procedure: on the one hand, RALP is acommon and routine intervention; on the other hand, en bloc cystectomy and nephro-ureterectomy is a rarely performed, extensive procedure requiring different patient positions, port locations and repeated docking/undocking. Furthermore, the classification of residency by year used in that study might not optimally reflect the actual proficiency level of residents in procedural assistance. In the context of a more complex routine procedure, such as robot-assisted partial nephrectomy, there was a significant association [34] or a strong trend (p = 0.051) [35] for an impact of the level of experience of the bedside assistant on the operative duration. Other perioperative benchmarks, e.g., blood loss, warm ischaemia time, and surgical margin status, did not differ [35].

These data suggest that en bloc simultaneous robot-assisted radical cystectomy and nephro-ureterectomy can be safely conducted with satisfactory mid-term oncological outcomes. With increasing experience, improved performance was detectable for the console surgeon but not in terms of the total operative duration. Simulation training of all team members for highly complex procedures might be a suitable approach for improving team performance.