Background and Surgical Outcomes for Robotic Prostatectomy

In the United States, nearly all radical prostatectomies are performed via the robotic approach using the da Vinci^® surgical system. Despite the widespread use and undeniable benefits of robotic prostatectomy, there remains significant variation in patient-reported outcomes (PRO) of urinary continence and erectile function.¹ In a recent study of over 4,500 patients from the Michigan Urological Surgery Improvement Collaborative (MUSIC), when evaluating patients with good baseline function, the rate at which individual surgeons’ patients reported good urinary function 3 months after surgery varied from 0% to 54.5% (fig. 1).² Patients receiving surgery from top-performing surgeons were more likely to report good 3-month function. This finding persisted after accounting for patient risk factors, supporting the role of surgical technique in achieving superior functional outcomes.

Figure 1. Surgeon-level variation in 3-month urinary continence after radical prostatectomy. Top-performing surgeons defined as surgeons with percentage of patients with good 3-month urinary function above 75th percentile for all surgeons.

Video Review and Quality Improvement

The dissemination of robotic surgery, which is easily amenable to video recording, has simplified the process of capturing and assessing technical performance.³ From a quality improvement perspective, video review is a practical method for assessing skill because it enables surgeons to review their performance, and reviewers to evaluate and learn from their peer’s performance at a convenient time. In MUSIC, we previously demonstrated the large-scale feasibility of assessing the technical skill of robotic surgeons and found that online crowdsourced reviewers agreed with expert surgeons on the rank order of surgeons with the lowest technical skill scores.⁴ A number of surgical approaches and technical modifications have been defined through video review, though the extent to which such variations in technique influence surgical outcomes is unclear.⁵ Ultimately, video review may facilitate standardization of the surgical approach and provide a mechanism by which the individual surgeon can improve outcomes with directed technical feedback.

MUSIC has employed a multi-faceted approach to facilitate improvement in key outcome measures for radical prostatectomy, including a target goal of 3-month urinary continence (0–1 pad/day) set at 75%. To achieve this quality measure, comprehensive patient-reported outcomes surgeon report cards are shared tri-annually in conjunction with didactic video review skills sessions. These sessions have included individualized video review with feedback, along with diverse panels of surgeons reviewing their own videos and describing important aspects of technique that are associated with improving functional outcomes and cancer control. Because of the COVID-19 pandemic, these have shifted to a webinar format (fig. 2). The advantage of the video format is that it still allows for sharing of technique and outcomes in a virtual format. Multiple surgeons from large and small group practices within MUSIC have stated these sessions have helped them become better surgeons with an improvement in their outcome data. Evaluating the data in MUSIC to determine whether video review improves population-level outcomes is the focus of our current efforts.

Figure 2. MUSIC video review skills webinar in October 2020 with MUSIC urologists. Dr. Peabody (left), Dr. Sarle (top right) and Dr. Hafron (middle right) discuss surgical technique with invited expert Dr. Abaza (bottom right).

MUSIC Robotic Surgery Video Library

Figure 3. User Interface of open access MUSIC Robotic Prostatectomy Video Library.

Figure 4. User interface for prototype crowdsourced surgical video annotation system.

The MUSIC Robotic Prostatectomy Video Library (www.musicurologyvideo.com), established in 2019, is an open-access forum for surgeons and trainees to review variations in surgical approach and technique. Including more than 60 de-identified surgeries from 31 MUSIC urologists, the platform is categorized by surgical performance—both technical skill and outcomes—using the MUSIC registry (fig. 3). Users have the ability to search videos according to surgeon-level urinary continence, biochemical recurrence, margin rate, perioperative morbidity, and surgeon-level readmission rate.⁶ The purpose of this platform is to provide the wider urological community access to MUSIC’s repository of videos and serve as an interactive forum for discussing surgical technique. Videos can be viewed according to technical steps of the procedure. To make the platform more user friendly, MUSIC has now begun to incorporate technical notes by the respective surgeon on set-up, approach, and tips/tricks.

Future Directions

Recent research shows that trainees at top-tier teaching hospitals in the U.S. rely on a progressive set of video review and annotation practices in order to learn surgery.⁷ In the past year we have collaborated to produce—and will soon begin testing—a prototype system to facilitate such learning that draws upon best-in-class human-computer interaction research on crowdsourced review and annotation of video data.⁸ Figure 4 illustrates key features of an alpha version of this system: review of surgical video via speed controls and a phase-segmented progress bar, semi-structured annotation of these videos (one per colored icon on the progress bar), and evaluation and discussion of these annotations. A system like this may allow users at all levels of seniority to improve their knowledge and technical skill, and we are excited about this work.

In summary, with increasing evidence that technical skill is correlated with patient outcomes, video review is a quality improvement intervention that can help surgeons improve their technique and promote a collaborative learning culture. As we continue to consume information digitally and interact with each other virtually, the role of online augmented tools to enable and accelerate learning will be further refined and will become an important tool to improve the quality of care for patients undergoing robotic surgery.

Please join us for our next skills workshop webinar in June 2021!