Efficiency and Accuracy of Robotic Surgical Performance Decayed Among Urologists During COVID-19 Shutdown
Year: 2020
Type: article
Abstract: Journal of EndourologyVol. 35, No. 6 Letters to the Editor Edited by Dean Assimos, MdFree AccessEfficiency and Accuracy of Robotic Surgical Performance Decayed Among Urologists During COVID-19 ShutdownBalint Der, Daniel Sanford, Ryan Hakim, Erik Vanstrum, Jessica H. Nguyen, and Andrew J. HungBalint DerCatherine & Joseph Aresty Department of Urology, Center for Robotic Simulation & Education, University of Southern California, Institute of Urology, Los Angeles, California, USA.Search for more papers by this author, Daniel SanfordCatherine & Joseph Aresty Department of Urology, Center for Robotic Simulation & Education, University of Southern California, Institute of Urology, Los Angeles, California, USA.Search for more papers by this author, Ryan HakimCatherine & Joseph Aresty Department of Urology, Center for Robotic Simulation & Education, University of Southern California, Institute of Urology, Los Angeles, California, USA.Search for more papers by this author, Erik VanstrumCatherine & Joseph Aresty Department of Urology, Center for Robotic Simulation & Education, University of Southern California, Institute of Urology, Los Angeles, California, USA.Search for more papers by this author, Jessica H. NguyenCatherine & Joseph Aresty Department of Urology, Center for Robotic Simulation & Education, University of Southern California, Institute of Urology, Los Angeles, California, USA.Search for more papers by this author, and Andrew J. HungAddress correspondence to: Andrew J. Hung, MD, Catherine & Joseph Aresty Department of Urology, Center for Robotic Simulation & Education, University of Southern California, Institute of Urology, 1141 Eastlake Avenue, Suite 7416, Los Angeles, CA 90089-9178, USA E-mail Address: [email protected]Catherine & Joseph Aresty Department of Urology, Center for Robotic Simulation & Education, University of Southern California, Institute of Urology, Los Angeles, California, USA.Search for more papers by this authorPublished Online:17 Jun 2021https://doi.org/10.1089/end.2020.0869AboutSectionsPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookXLinked InRedditEmail IntroductionThe COVID-19 pandemic has severely impacted health care delivery worldwide. In March 2020, the United States Surgeon General recommended postponing all elective procedures in the United States, resulting in a dramatic decrease in caseloads across surgical specialties.1 The potential degradation of surgical skills during the pandemic and this surgical hiatus has not yet been studied. The association between surgeon performance and clinical outcomes is strong.2 Our own study has demonstrated that suturing performance is associated with long-term recovery of urinary continence after robotic prostatectomy.3 Herein, we evaluate suturing skill degradation succeeding the COVID-19 shutdown.MethodsSurgeons completed a series of robotic virtual reality (VR) exercises immediately before and after a mandated 6-week surgical hiatus (Fig. 1a). Assessment of computer-generated metrics and objective robotic surgical skills has been extensively studied and validated in VR simulation.4 We collected simulator generated metrics of surgeon efficiency and precision (Fig. 1b). In addition, three independent and blinded reviewers (B.D., D.S., and R.H.) evaluated suturing technical skill utilizing a validated assessment tool.5 Reviewers initially assessed cases independently before reaching a consensus score for discrepant gradings. Surgeons reported their perception of skills based on a survey questionnaire postshutdown. Depending on the results of the D'Agostino–Pearson normality test, comparisons of surgical performance before/after the shutdown were performed with either paired Student's t-test or Wilcoxon-matched signed-rank test. The graphical presentations of subgroup analyses were omitted where p > 0.05.FIG. 1. Study overview and assessment parameters. (a) The study timeline indicating the periods of data collection and the duration of the COVID-19 shutdown. (b) Study design and representative image of simulator exercise. (c) COVID-19-shutdown-related surgical caseload drop-off. (d) Time to complete exercise in all participants, experts, and trainees. (e) The comparison of needle handling time. (f) The comparison of needle targeting accuracy. (g) The comparison of instrument collisions. (h) Qualitative assessment of suturing skill. (i) Self-rated assessment of skills before and after the COVID-19-shutdown. NS p > 0.05, *p < 0.05, **p < 0.01, ****p < 0.0001 column heights represent averages. NS, not significant.ResultsSixteen surgeons completed the VR sessions pre- and post-COVID-19 shutdown. Urologic surgeons were classified a priori as trainee (<300 cases, n = 7, residents+junior fellows) or expert (≥300 cases, n = 9, senior fellows+faculty). Weekly robotic caseload decreased from median 5.5 (1–12.5) to 1 (0–3) cases during the shutdown (p < 0.0001; Fig. 1c).Overall, exercise completion time increased by 17% for the entire cohort as compared with baseline (p = 0.0056; Fig. 1d). Specifically, trainees required more time to finish the exercise (p = 0.0313). Within the suturing sequence (needle handling, targeting, driving), the needle handling component accounted for the increased task completion time (experts+trainees: p = 0.0459; experts: p = 0.0469, Fig. 1e). Targeting accuracy and instrument collisions (precision metrics) declined during the shutdown. Overall, needle targeting accuracy decreased from median 80% (44–100) to 67% (46–80) (p = 0.0148; Fig. 1f); however, experts accounted for a more robust decrease from median 84% (63–100) to 68% (60–80) (p = 0.0313). Instrument collision events showed no overall increase; however, experts had a significant increase in collisions (p = 0.0497; Fig. 1g). Technical skill evaluation revealed that experts' ability to achieve optimal needle entry angle declined (p = 0.0112; Fig. 1h). Finally, surgeons reported a significant decrease in their perception of robotic surgical skills after the shutdown (trainees: from median 7 (7–9) to 6 (4–9), p = 0.125; experts: from median 8.5 (7–10) to 8.5 (7–9), p = 0.3506, experts+trainees: p = 0.0335; Fig. 1i).DiscussionOur study collected detailed surgical performance data in a controlled environment before and after the COVID-19 shutdown. A profoundly disruptive event such as a pandemic that has impacted all surgeons simultaneously has not been seen previously. In just 6 weeks, we show significant decay in efficiency and precision metrics alongside technical surgical skills. This is the first study to evaluate surgical skills degradation in expert surgeons. Of note, experts demonstrated a significant decrease in precision similarly to newly trained surgeons.6 The decreased accuracy, efficiency, and perception of skills warrant further investigation on how the COVID-19 shutdown may be impacting clinical outcomes. This study is potentially limited by its focus on suturing performance without evaluation of other technical skills used in surgery. Future study should focus on methods of retaining surgical skills during more common periods of inactivity (i.e., regular skill maintenance training on VR simulator7 during sabbatical, maternity/paternity leave).IRB Approval and Human and Animal RightsOur study complied with protocols approved by the University of Southern California's IRB. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. This article does not contain any studies with animals performed by any of the authors.Informed ConsentInformed consent was obtained from all individuals included in the study.Authors' ContributionsB.D. was in charge of the project development, data collection, data analysis, and article writing. D.S. performed data analysis and article writing. R.H. did data collection, data analysis, and article editing. E.V. performed data management and article editing. J.H.N. did data collection and article editing. A.J.H. was in charge of project development, data management, and article writing.Authors' Disclosure StatementA.J.H. is a consultant for Mimic, Quantagene, and Johnson & Johnson. The study was not funded by any of these companies. Other authors have no conflict of interest.Funding InformationResearch reported in this publication was supported in part by the National Institute of Biomedical Imaging and Bioengineering of the National Institutes of Health under Award No. K23EB026493.References1. Nepogodiev D, Omar OM, Glasbey JC, Li E, Simoes JFF, et al. Elective surgery cancellations due to the COVID-19 pandemic: Global predictive modelling to inform surgical recovery plans. Br J Surg 2020;10.1002/bjs.11746. Crossref, Google Scholar2. Birkmeyer JD, Finks JF, O'Reilly A, et al. Surgical skill and complication rates after bariatric surgery. N Engl J Med 2013;369:1434–1442. Crossref, Medline, Google Scholar3. Hung AJ, Chen J, Ghodoussipour S, et al. A deep-learning model using automated performance metrics and clinical features to predict urinary continence recovery after robot-assisted radical prostatectomy. BJU Int 2019;124:487–495. Crossref, Medline, Google Scholar4. Hovgaard LH, Andersen SAW, Konge L, Dalsgaard T, Larsen CR. Validity evidence for procedural competency in virtual reality robotic simulation, establishing a credible pass/fail standard for the vaginal cuff closure procedure. Surg Endosc 2018;32:4200–4208. Crossref, Medline, Google Scholar5. Raza SJ, Field E, Jay C, et al. Surgical competency for urethrovesical anastomosis during robot-assisted radical prostatectomy: Development and validation of the robotic anastomosis competency evaluation. Urology 2015;85:27–32. Crossref, Medline, Google Scholar6. Jenison EL, Gil KM, Lendvay TS, Guy MS. Robotic surgical skills: Acquisition, maintenance, and degradation. JSLS 2012;16:218–228. Crossref, Medline, Google Scholar7. Guseila LM, Saranathan A, Jenison EL, Gil KM, Elias JJ. Using virtual reality to maintain surgical skills during periods of robotic surgery inactivity. J Robot Surg 2014;8:261–268. Crossref, Medline, Google ScholarAbbreviations UsedVRvirtual realityNSnot significantFiguresReferencesRelatedDetailsCited byHealth Care Simulation as a Training Tool for Epidemic Management7 March 2023 | Simulation in Healthcare: The Journal of the Society for Simulation in Healthcare, Vol. 18, No. 6Recovery of Skill Decay After COVID-19 Redeployments and Implications for Competency AttainmentJournal of Surgical Research, Vol. 285The Impact of COVID-19 on Surgical Training and Education16 February 2023 | Cancers, Vol. 15, No. 4Virtual reality in human-robot interaction: Challenges and benefitsElectronic Research Archive, Vol. 31, No. 5Association of Suturing Technical Skill Assessment Scores Between Virtual Reality Simulation and Live Surgery Daniel I. Sanford, Runzhuo Ma, Alireza Ghoreifi, Taseen F. Haque, Jessica H. Nguyen, and Andrew J. Hung4 October 2022 | Journal of Endourology, Vol. 36, No. 10Impact of Severe Acute Respiratory Syndrome Coronavirus 2-Induced COVID-19 on Fixed Operating Room Times in Urologic OperationsMayo Clinic Proceedings: Innovations, Quality & Outcomes, Vol. 6, No. 4Technical Skill Impacts the Success of Sequential Robotic Suturing Substeps Daniel I. Sanford, Balint Der, Taseen F. Haque, Runzhuo Ma, Ryan Hakim, Jessica H. Nguyen, Steven Cen, and Andrew J. Hung1 February 2022 | Journal of Endourology, Vol. 36, No. 2 Volume 35Issue 6Jun 2021 InformationCopyright 2021, Mary Ann Liebert, Inc., publishersTo cite this article:Balint Der, Daniel Sanford, Ryan Hakim, Erik Vanstrum, Jessica H. Nguyen, and Andrew J. Hung.Efficiency and Accuracy of Robotic Surgical Performance Decayed Among Urologists During COVID-19 Shutdown.Journal of Endourology.Jun 2021.888-890.http://doi.org/10.1089/end.2020.0869Published in Volume: 35 Issue 6: June 17, 2021Online Ahead of Print:December 11, 2020Online Ahead of Editing: November 15, 2020 TopicsCOVID-19 PDF download
Source: Journal of Endourology
Institution: University of Southern California
Language: English
Subfield: Surgery
Field: Medicine
Domain: Health Sciences
Open Access status: green
OpenAlex ID: W3099250301