"Robotic Fatigue?" - the Impact of Case Order on Positive Surgical Margins in Robotic-Assisted Laparoscopic Prostatectomy

With the advances in minimally invasive surgery and increased familiarity with robotic-assisted laparoscopic prostatectomy (RALP), there has been a trend towards performing multiple robotic cases per day. An area once dominated by single prostatectomy in a day has now grown exponentially. The limits are constantly being pushed to not only minimize the invasiveness of prostate cancer surgery without compromising oncologic or functional outcomes but to also do this efficiently and quickly.

This evolution has directly affected the number of cases per day, resulting in almost a universal acceptance of two to three prostatectomies per day as being the new “normal”. High volume hospitals are assumed to have the structural characteristics associated with a better quality of care, and providers in these hospitals are thought to improve their processes of care through experience in providing complex care. While the high-volume systems are primed for this increase in robotic volume, are the surgeons equipped to handle this equally as well?

Operating can be both mentally and physically draining, a finding that is only perpetuated by consecutive surger6ies. Despite improved ergonomics and dexterity provided by robotics, over 40% of surgeons performing robotic prostatectomies report chronic back pain and mental fatigue, which is further exacerbated by performing sequential surgical procedures.

To better understand the role of robot fatigue on surgical outcomes, we aimed to evaluate whether performing consecutive (i.e., “back-to-back”) RALP by a single surgical team would impact immediate surgical outcomes through assessment of intraoperative variables such as blood loss, operative time, lymph node yield, and positive surgical margin (PSM).

PSM after RALP has been established to have a significant increase of biochemical recurrence in patients with prostate cancer. We chose to use PSM as a predictor of surgical accuracy, expertise, and robotic fatigue due to its subjective nature and standardized reporting.

Overall, among the eight institutions, there was no significant difference in PSM rate between the first and the second case of the day. These findings do have to be interpreted with caution, as there was evidence that the PSM has significant institutional variability, with multiple institutions having a higher PSM in the latter case of the day.

While this study has certainly opened up a necessary discussion about the role of robotic fatigue and the limitation of the surgeon, in the authors’ perspective, it has also brought to light the reluctance of institutional participation of surgical quality reporting.

The quality of surgical care is a complex topic that lies at the cross-section of patient safety, surgical decision making, anesthesia safety, and institutional values. Not surprisingly, despite the clinical and oncologic implications of PSM and the need for accurate reporting to the public, the risk of potential de-identification of the institution and the surgeon has proven to become a significant barrier to participation in these multi-institutional collaborations. The authors of this study want to applaud the institutions that did participate, not only for their transparent reporting and willingness to collaborate but for setting an example of an institutional culture aimed at ensuring optimal patient outcomes.

Written by: Laura Bukavina, MD, MPH, Urology Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio, and Lee Ponsky, MD, Case Comprehensive Cancer Center, Case Western Reserve University School of Medicine, Cleveland, Ohio

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