Better to be your surgeon's first RALP patient of the day rather than the second?

“Robotic fatigue?” – The impact of case order on positive surgical margins in robotic-assisted laparoscopic prostatectomy (2020, Full Text)

"Highlights

• Case Sequence of robotic prostatectomy was not associated with worse surgical outcomes including surgical margin rate.

• Factors associated with increased rate of positive surgical margin include higher pre-operative PSA, higher percent tumor involvement, extra prostatic extension, and presence of seminal vesicle invasion.

• Second case of the day did experience statistically higher blood loss compared to the first prostatectomy of the day.

• Overall, a trend for a higher positive surgical margin rate in second case of the day was observed, a finding that was variable amongst institutions.

Abstract

Purpose
Multiple robotic-assisted surgeries are often performed within a single operating day; however, the impact of this practice on patient outcomes has not been examined. We aim to determine whether outcomes for robotic-assisted laparoscopic prostatectomy (RALP) differed when performed sequentially.

Materials and methods
A multi-institutional, retrospective cohort study was conducted involving a total of 8 academic centers between years 2015 and 2018. Participants were adult males undergoing RALP for localized prostate cancer on operative days in which 2 RALP cases were performed sequentially by the same resident-attending team. The primary outcome of the study was presence of positive surgical margin (PSM). Secondary outcomes were lymph node yield, operative time, and estimated blood loss. The primary analysis was a random effects meta-analysis model for PSM.

Results
Overall, 898 RALP cases (449 sequential pairs) were included in the study. There was no significant difference in PSM rate (27.2% vs. 30.3%, P= 0.338) between first and second case groups, respectively. Utilizing random effects meta-analysis, the second case cohort had no increased risk of PSM (OR 0.761.231.97, P= 0.40). Higher blood loss was noted in the second case cohort (186.7 ml vs. 221.7 ml, P = 0.002). Additionally, factors associated with PSM were increasing prostate specific antigen, higher percent tumor involvement, extraprostatic extension, and seminal vesicle invasion.

Conclusion
Case sequence was not associated with PSM, lymph node yield, or operative time for RALP. Disease specific factors and institutional experience are associated with increased risk for positive surgical margin which can aid providers in scheduling of patients."

From the Full Text:

"...
Operating can be mentally and physically draining, a finding that is only exacerbated by consecutive surgeries (4). Despite substantial improvement in ergonomics and in dexterity provided by robotic surgery; over 40% of urologic surgeons performing prostatectomies reported chronic back pain and mental fatigue which was exacerbated by performing sequential surgical procedures (5). Despite knowledge of the presence of both physical and mental fatigue with prolonged and sequential operations, we have little knowledge on how this impacts surgical outcomes (6,7).
...
Conclusion
Oncologic operations are both mentally and physically demanding. With the dissemination and quick adoption of robotic surgery in community and academic settings, there has been an uptrend in performing sequential surgeries. There is no statistically significant difference in PSM, lymph node yield, or operative time dependent upon case sequencing for RALP. Disease specific factors and institutional experience are associated with increased risk for positive surgical margin which can aid providers in scheduling of patients."

[Emphasis mine]

In addition to "aid[ing] providers in scheduling of patients," should the patient have a say (e.g. "Me first, please)" ?

If your friend is having a RP, would you tell him to ask to be patient 1 rather than 2 on the day of his surgery? I wonder if surgeons performing two RALPs schedule the more serious case first.

My surgeon does only open procedures (and mine took 4 hours, although there may have been some down time waiting for frozen-section results). I'll ask next visit if he ever does 2 RPs and how he schedules the order. For the majority of you who had RALP, do you know how many procedures your surgeon does in a day or morning?

Djin

I assume most surgeons start major elective procedures very early because patients are NPO. Also, team members could get tied up during the day, making later team start times problematical.

Djin

Pratoman said...
I was told i would be first of the day which i requested. They had me arrive at the hospital at 5:30am. I sat and waited until past noon. Turns out they had me in the third slot. I was very annoyed, and always wondered if i was first, would i have had a positive intra-operative margin which presumably led me to ADT+SRT. I'll never know

Are you sure your were third with the same surgeon/team or perhaps third with the room/robot and first with your team?

Djin

Sr Sailor said...
Any studies on whether hangovers have an effect on surgical outcomes of early morning patients?
😊

Hangovers and hangnails.

<< I think he does 3-4 a day. He does surgery 4 days a week and sees patients on Fridays. >>

Wow, wow, wow. That volume either keeps the surgeon razor sharp, or he is pushing himself to dangerous limits. To me, it seems like waaaay to much.

My open surgery was done on the 11th second of the 11th minute of the 11th hour of the 11th day of the 11th month yada yada yada...hoping to kill two threads that got under the wire(barbed of coarse) of the "time" zone...

BTW urban legend has it that Groucho Mark's last words were "I've either died or my watch has stopped"

halbert said...
...
What does this suggest about the famous PC surgeon who does way more than 4 a day and moves from room to room to "do the procedure" while assistants do everything except the actual prostate removal?

That he has comfortable shoes.

Come to think of it, I was taken in to surgery later in the morning, and I think my doc did have a procedure before mine (may or may not have been a RP). Anyhoo, I had negative margins and he said he (at a later visit) had no difficulties --that my prostate "popped right out." As I mentioned it was a 4-hr operation, so I take the description to mean he had no difficulty in separating the prostate from surrounding tissue.

Djin

Prato,
I'll bet he's an outstanding surgeon, and I think you made a good decision for selecting him. I'm just hoping not too many those thousands of surgeries were on guys with one or two G6 cores. 🙂

and then there is this quote from who I don't know...' the captain of the Titanic had 30 years of experience working against him'

BTW aside from my attempt at bringing veterens day into focus by the 11th second shtick...do you guys get any of my shticks...I really do expect too much of people and so it goes...and the there is this..,

My open surgery was on a monday morning first thing...and it was... 4 1/2 hours long with 29 lymph nodes removed ...al negative....I broke the ice with the doctor...when he did a dre on inital consult upon arrival at the Dub and as he was doing it I offered him some surf lessons on maui...he balked...I caught it ...and told him not to worry I did'nt want to be his arse hole body..just an offer...he and his assistant ..totally broke all protocol and burst out laughing,,,and we were all arse hole buddies thence on true story,,,he yanked the walnut....did the nerve sparingand closed it up..being a teaching hospital...the plebes did the nodes basically establishing a firewall apparently it worked I reckon... what me worry???

I requested to be the first case of the day for a number of reasons and I was the first case of the day (Robotic).

1) More likely to start on time. Any case can run long but if you are the first case you avoid many causes of being delayed. Delay in my case causes anxiety.
2) Fresh crew (Anesthesia, Techs, Surgeon, Recovery staff, Pre-op staff)
3) My family was able to visit with me postoperatively and still make the 70 drive back home before it got dark
Hero

Never have surgery on Monday or Friday and never after Happy Hour....