Hinata N, et al. World J Mens Health. 2022 Jan;40:e2. https://doi.org/10.5534/wjmh.210070

Objective: To analyse ambulatory movements and team dynamics during robot‐assisted surgery ( RAS ), and to investigate whether congestion of the physical space associated with robotic technology led to workflow challenges or predisposed to errors and adverse events. Methods: With institutional review board approval, we retrospectively reviewed 10 recorded robot‐assisted radical prostatectomies in a single operating room ( OR ). The OR was divided into eight zones, and all movements were tracked and described in terms of start and end zones, duration, personnel and purpose. Movements were further classified into avoidable (can be eliminated/improved) and unavoidable (necessary for completion of the procedure). Results: The mean operating time was 166 min, of which ambulation constituted 27 min (16%). A total of 2 896 ambulatory movements were identified (mean: 290 ambulatory movements/procedure). Most of the movements were procedure‐related (31%), and were performed by the circulating nurse. We identified 11 main pathways in the OR ; the heaviest traffic was between the circulating nurse zone, transit zone and supply‐1 zone. A total of 50% of ambulatory movements were found to be avoidable. Conclusion: More than half of the movements during RAS can be eliminated with an improved OR setting. More studies are needed to design an evidence‐based OR layout that enhances access, workflow and patient safety.

Comprehensive training and skill acquisition by urological surgeons are vital to optimize surgical outcomes and patient safety. We sought to develop and validate PACE (Prostatectomy Assessment and Competence Evaluation), an objective and procedure specific tool to assess the quality of robot-assisted radical prostatectomy. Development and content validation of PACE was performed by deconstructing robot-assisted radical prostatectomy into 7 key domains utilizing the Delphi methodology. Reliability and construct validation were then assessed using de-identified videos performed by practicing surgeons and fellows. Consensus for each domain was defined as achieving a content validity index of 0.75 or greater. Reliability was assessed by the intraclass correlation and construct validation using a mixed linear model accounting for multiple ratings on the same video. After 3 rounds consensus was reached on wording, relevance of the skills assessed and concordance between the score assigned and the skill assessed. An intraclass correlation of 0.4 or greater was achieved for all domains. The expert group outperformed trainees in all domains but reached statistical significance in bladder drop (4.5 vs 3.4, p = 0.002), preparation of the prostate (4.4 vs 3.2, p <0.0001), seminal vesicle and posterior plane dissection (8.3 vs 6.8, p = 0.03), and neurovascular bundle preservation (4.1 vs 2.4, p <0.0001). Limitations included the lack of assessment of other key skills such as communication and decision making. PACE is a structured, procedure specific and reliable tool that objectively measures surgical performance during robot-assisted radical prostatectomy. It can differentiate different levels of expertise and provide structured feedback to customize training and surgical quality improvement.