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OBJECTIVE: We evaluated the feasibility, safety, and learning curve of extraperitoneal single-port robot-assisted radical prostatectomy (SP-RARP) and introduced innovative surgical techniques to maintain the instrument positions during the procedures.
METHODS: A cohort of 100 patients underwent extraperitoneal SP-RARP at our institution from December 2021 to April 2023. The procedures were performed by an experienced urology surgeon utilizing two surgical techniques for dissecting the posterior aspect of the prostate-\"changing instrument roles\" and \"using camera inversion\"-to prevent positional shifts between the camera and instruments.
RESULTS: The mean operation time for SP-RARP was 93.58 minutes, and the mean console time was 65.16 minutes. The mean estimated blood loss during the procedures was 109.30 mL. No cases necessitated conversion to multi-port robot, laparoscopy, or open surgery, and there were no major complications during the hospital stay or in the short-term follow-up. Early outcomes of post-radical prostatectomy indicated a biochemical recurrence rate of 4.0% over a mean follow-up duration of 6.40 months, with continence and potency recovery rates of 92.3% and 55.8%, respectively. Analysis of the learning curve showed no significant differences in operation time, console time, and positive surgical margin rates between the initial and latter 50 cases.
CONCLUSIONS: Extraperitoneal SP-RARP is a feasible and safe option for the treatment of localized prostate cancer in skilled hands. Continued accrual of cases is essential for future comparisons of SP-RARP with multiport approaches.

BACKGROUND: This article attempts to provide a comprehensive review of the learning objectives and importance of the supine percutaneous nephrolithotomy (PCNL) technique.
METHODS: We retrospectively reviewed the cases of Supine PCNL between January 2018 and January 2024. We divided the groups into 3: residents between 2 and 3 years (Group 1), residents between 4 and 5 years (Group 2), and endourologist (Group 3). The 2-3-year resident started to perform PCNL for the first time, while the 4-5-year resident started to perform Supine PCNL for the first time while previously performing prone PCNL.
RESULTS: Access, fluoroscopy, and operation time were higher in Group 1, shorter in Group 2, and shortest in Group 3 (p < 0.001). Postoperative length of stay and the need for additional treatment were found to be shorter (p < 0.001), and the stone-free rate (SFR) increased (p < 0.001) from Group 1 to Group 3. The highest complication rates were observed in Group 1 (p = 0.002). SFR rate increased as the number of cases increased in Group 1 patients. Success was stable after 46-60 cases in terms of SFR. In Group 2, the SFR rate was stable after 31-45.
METHODS: The most complications were observed in Group 1 and the least in Group 3.
CONCLUSIONS: In 2-3-year residents, access time and fluoroscopy time decrease with experience. In 4-5-year residents, due to their expertise in prone PCNL, the operation time and fluoroscopy time decrease with the number of cases performed. SFR is higher after 46-60 cases for 2-3-year residents and 31-45 cases for 4-5-year residents.

BACKGROUND: Implementing new approaches or new implants is always related with a certain learning curve in total hip arthroplasty (THA). Currently, many surgeons are switching to minimally invasive approaches combined with short stems for performing THA. Therefore, we aimed to asses and compare the learning curve of switching from an anterolateral Watson Jones approach (ALA) to a direct anterior approach (DAA) with the learning curve of switching from a neck-resecting to a partially neck-sparing short stem in cementless THA.
METHODS: The first 150 consecutive THA performed through a DAA (Group A) and the first 150 consecutive THA using a partially neck-sparing short stem (Group B) performed by a single surgeon were evaluated within this retrospective cohort study. All cases were screened for surgery related adverse events (AE). Furthermore, the operative time of each surgery was evaluated and the learning curve assessed performing a cumulative sum (CUSUM) analysis.
RESULTS: Overall, significantly more AE occurred in Group A compared to Group B (18.0% vs. 10.0%; p = 0.046). The sub-analysis of the AE revealed higher rates of periprosthetic joint infections (2.7% vs. 0.7%; p = 0.176), periprosthetic fractures (4.0% vs. 2.0%; p = 0.310) and overall revisions (4.7% vs. 1.3% p = 0.091) within Group A without statistical significance. The CUSUM analysis revealed a consistent reduction of operative time after 97 cases in Group A and 79 cases in Group B.
CONCLUSIONS: A significantly higher overall rate of AE was detected while switching approach compared to switching implant for performing THA. However, according to the results of this study, surgeons should be aware of the learning curve of the adoption to a new implant with different fixation philosophy as well.

OBJECTIVE: MRI-based VI-RADS score aids in differentiating MIBC and NMIBC, but the experience\'s impact remains unexplored. We aimed to determine the effect of accumulating experience in the diagnostic performance of VI-RADS.
METHODS: In our previously published series 71 primary bladder cancer patients who underwent multiparametric MRI before the transurethral resection were analyzed. The radiologist who assessed the VI-RADS scores at the time the study was performed, re-evaluated all cases after 3 years, in a blinded fashion. During these three years, more than 300 additional bladder MRIs were performed for VI-RADS assessment. The diagnostic performances of the initial and subsequent VI-RADS analyses were compared. Moreover, VIRADS results obtained by a newly trained abdominal radiologist was also compared with experienced radiologist\'s results. For this study, VI-RADS ≥3 was accepted for predicting MIBC.
RESULTS: Overall 71 patients [62 (87.3 %) males, 67.4 ± 10.2 years] who underwent bladder MRI before TURBT were included. Histopathology revealed MIBC in 16 (26.2 %) cases. The initial MRI analysis revealed VI-RADS score ≥ 3 in 36 (50.7 %) cases. The sensitivity and specificity for depicting MIBC were 75 % and 56.4 % respectively. The subsequent MRI analysis revealed VI-RADS score ≥ 3 in 23 (32.4 %) cases. The sensitivity and specificity were 93.8 % and 85.5 % respectively. The MRI analysis performed by the recently trained abdominal radiologist revealed VI-RADS score ≥ 3 in 24 (33.8 %) cases. The sensitivity and specificity were 87.5 % and 56.4 % respectively.
CONCLUSIONS: The diagnostic performance of VI-RADS for the interpretation of bladder MRI can improve over time by increasing the experience of the urogenital radiologist.

Minimally invasive procedures minimize trauma to the human body while maintaining satisfactory therapeutic results. Minimally invasive pancreas surgery (MIPS) was introduced in 1994, but questions regarding its efficacy compared to an open approach were widespread. MIPS is associated with several perioperative advantages while maintaining oncological standards when performed by surgeons with a robust training regimen and frequent practice. Future research should focus on addressing learning curve discrepancies while identifying factors associated with shortening the time needed to attain technical proficiency.

BACKGROUND: Endoscopic submucosal dissection (ESD) is a specialised endoscopic technique in the treatment of large pre-cancerous and early cancerous gastrointestinal lesions that avoids the need for surgical resections. The objective of this study was to assess the feasibility, efficacy and safety of learning ESD in an untutored approach in a prevalence-based setting within New Zealand.
METHODS: Over a 4-year period, 80 ESD procedures were performed at a single tertiary centre within New Zealand. We retrospectively reviewed basic demographics of the patients, along with successful en bloc resection rates, dissection speeds, histological diagnoses (including margin assessments) and complications.
RESULTS: We captured 80 procedures. Within this database we achieved an en bloc resection of 88.7% (71 out of 80 cases) and an R0 resection of 72.5% (58 out of 80 cases). The international benchmark for dissection speed of 9cm2/h was achieved within the first block of 20 cases and was maintained throughout. There was a perforation rate of 6.25% (five patients), with one patient (1.25%) requiring emergency surgery for a rectal perforation.
CONCLUSIONS: Our study shows it is feasible and safe to learn ESD within a low-volume tertiary centre within New Zealand via a prevalence-based approached. The majority of patients were able to have en bloc resection and a R0 resection. Our intent is that this data be used to help design a more formalised training process for learning ESD within a New Zealand setting.

OBJECTIVE: To assess the accuracy and effectiveness among operators with different levels of experience in a robot-assisted immediate implant surgery.
METHODS: The study included four participants who had received dental training at the same institution but have varying levels of clinical experience in implant dentistry, denoted as undergraduate student (UG), dental resident (DR), specialist with no robot experience (IS) and specialist with robot experience (RS). Following comprehensive theoretical training in robot-assisted implant operation, each operator participated in five robotic-assisted implant procedures at 21 sites, resulting in the implant surgery of a total of 20 implants. Subsequently, the accuracy of the implants was assessed by analyzing the preoperative planning and the postoperative CBCT scans, and the time required for each procedure was also recorded.
RESULTS: Angular deviation in UG, DR, IS and RS group was 0.82 ± 0.27°, 0.55 ± 0.27°, 0.83 ± 0.27°, and 0.56 ± 0.36°, respectively. The total deviation of the implant platform point was 0.28 ± 0.10 mm, 0.26 ± 0.16 mm, 0.34 ± 0.08 mm and 0.31 ± 0.06 mm, respectively. The total deviation of the apical point was 0.30 ± 0.08 mm, 0.25 ± 0.18 mm, 0.31 ± 0.09 mm, and 0.31 ± 0.05 mm, respectively. The time spent was 10.37 ± 0.57 min, 10.56 ± 1.77 min, 9.93 ± 0.78 min, and 11.76 ± 0.78 min for each operator. As the number of operations increased, the operation time decreased, but there was no significant difference in implant accuracy between the different groups.
CONCLUSIONS: Within the scope of this study, robot-assisted implant surgery demonstrated high accuracy, with no significant differences in performance between operators with varying levels of clinical experience or implant robot-user experience. Furthermore, the learning curve for robotic implant surgery is steep and consistent.
CONCLUSIONS: Robot-assisted implant surgery demonstrates consistent high accuracy across operators of varying clinical and robotic experience levels, highlighting its potential to standardize procedures and enhance predictability in clinical outcomes.

UNASSIGNED: In the use of medical device procedures, learning effects have been shown to have a significant impact on the outcome, and are a critical component of medical device safety surveillance. To support estimation of these effects, we evaluated our methods for modeling these rates within several different actual datasets representing patients treated by physicians clustered within institutions to show the flexibility of this method across applications.
UNASSIGNED: In order to estimate the learning curve effects, we employed our unique modeling for the learning curves to incorporate the learning hierarchy between institution and physicians, and then modeled them within established methods that work with hierarchical data such as generalized estimating equations (GEE). Within the actual datasets, we looked at two device types and also two procedure types which had not been observed before: off pump coronary artery bypass (CABG) experience, and radial access experience. We also tried mediation analyses within the GEE framework for these various devices/procedures as well.
UNASSIGNED: We found that the choice of shape used to produce the \"learning-free\" dataset would still be dataset specific depending upon needs for modeling fast or slow learning but that in general the power series or logarithmic shapes would be better for modeling slower learning while exponential may be better for faster learning. Mediation analysis also showed promise in adapting the modeling of the learning curve.
UNASSIGNED: In showing the flexibility of using our method in various applications; this time utilizing more than one possible procedure done per patient so that each physician had more volume, we were able to show the flexibility of applying our method in different data applications to allow for more accurately capturing the learning curve rates in physicians nested within institutions. This can, therefore, be used across the board for device and procedure safety.

BACKGROUND: We aimed to introduce our modified hand-assisted retroperitoneoscopic living donor nephrectomy (HARPLDN) technique and define the learning curve.
METHODS: One hundred thirty-eight kidney donors who underwent modified HARPLDN by the same surgeon between May 2015 and March 2022 were included. A cumulative sum (CUSUM) learning curve analysis was performed with the total operation time as the study outcome.
RESULTS: In total, the mean operative time was 138.2 ± 32.1 min. The median warm ischemic time (WIT) and estimated blood loss were 90 s and 50 ml, respectively. The learning curve for the total operative time was best modeled as a second-order polynomial with the following equation: CUSUMOT (min) = (-0.09 case number2) + (12.88 case number) - 67.77 (R2 = 0.7875; p<0.05). The CUSUM learning curve included the following three unique phases: phase 1 (the initial 41 cases), representing the initial learning curve; phase 2 (the middle 43 cases), representing expert competence; and phase 3 (the final 54 cases), representing mastery. The overall 6-month graft survival rate was 99.3%, with 94.9% immediate onset of graft function without delayed graft function and 0.7% ureteral complications.
CONCLUSIONS: Our modified method is safe and effective for living donor nephrectomy and has the advantages of a shorter operating time and optimized WIT. The surgeon can become familiar with the modified HARPLDN after 41 cases and effectively perform the next 97 cases.