Robot-Assisted Radical Prostatectomy: A Survey on the Inuence of Postoperative Results Analysis and Surgical Video Review on Postoperative Complications and Functional Results.

Background: Effective training and assessment of performance are fundamental to ensuring that surgeons reach their intended goal and operate safely with maximum preservation of functions. The eld of video review and postoperative results analysis is focused on predicting postoperative results and reducing complications. Even though multiple groups have investigated the possibility of video review it is unclear if video review has found its place in daily clinical practice. To investigate the experiences and opinions of surgeons in the eld of Robot-assisted Radical Prostatectomy (RARP) on the inuence of video reviews and postoperative results analysis on postoperative complications and functional results. Design, Setting, and Participants: RARP surgeons who were expected to perform video reviews and postoperative results analysis were identied. A total of 93 RARP surgeons were invited to participate in this survey. Online questionnaires were distributed. The questionnaire contained the following domains: background information of the RARP surgeons, evaluation of the use of postoperative results analysis and surgical video review, and future recommendations. Results: A total of 30 RARP surgeons responded to the questionnaire. 27 respondents organized periodical results analyses, 17 of them reviewed edited videos as part of standard clinical practice in their hospital. Most respondents recommend video review, and are convinced it improves outcomes through self-reection, feedback from a colleague, or from seeing different techniques and ‘tricks’. Conclusion: RARP surgeons have accepted the implementation of postoperative results analysis and surgical video review as forms of quality assurance and self-reection. They use edited surgical videos to gain insight into the specic facets of RARP related to postoperative complications and functional outcomes.


Introduction
In the USA, approximately 90% of the radical prostatectomy surgeries are performed using the surgical robot,. 1 i.e. Robot-Assisted Radical Prostatectomy (RARP). The in uence of the surgical skills during RARP on surgical complications and functional outcomes has been investigated, but the speci c surgical steps in uencing urinary continence and erectile function remain unclear so far. [1][2][3] In general, laparoscopic and robotic surgery provides the possibility to evaluate surgeons' skills based on intracorporal surgical videos. 4,5 Analysis of these videos offers the opportunity to gain insight into past performance and to relate intraoperative events to adverse postoperative outcomes to learn for the future [6][7][8][9] .
Effective training and assessment of performance are fundamental to ensuring that surgeons reach their intended goal and operate safely with maximum preservation of functions. 7,10, 11 The eld of video review and postoperative results analysis is focused on predicting postoperative results and reducing complications. 1,2,12,13 Even though multiple groups have investigated the possibility of video review it is unclear if video review has found its place in daily clinical practice. Earlier research of our group has shown Dutch experts are willing to participate in surgical video review. 1

Surgeon panel
The surgeons were identi ed based on a multitude of factors: expected to perform video reviews and postoperative results analysis, have a known scienti c interest in RARP through publications, have a high caseload, recommendation by an expert (HvdP), being a proctor or educator of a robotic fellowship, or being a staff member in one of the CC-ERUS-EAU host centers. Based on these (soft) criteria 93 RARP surgeons were invited to participate in this survey. Informed consent was obtained from all participants included in the study.

Questionnaire
The questionnaire (supplementary data 1) contained questions on: background information about the respondents, evaluation of the use of postoperative results analysis, evaluation of the use of surgical video review, the in uence of postoperative results analysis and surgical video review on daily practice, and future recommendations on postoperative results analysis and surgical video review. The questionnaire was sent using the self-service function of the Data Management module developed by Research Manager https://my-researchmanager.com/en/home-2/.

Statistical analysis
In this descriptive study, data was presented as frequency distribution with percentages. Data was analyzed with SPSS v25 (IBM Corp., Armonk, NY, USA).

Results
A total of 30 RARP surgeons (32%) responded to the survey, two responses were incomplete. A total of 24 (80%) had at least ve (or more) years of experience (Table 1). A total of 22 (73%) participants performed more than 500 RARPs in their career. The hospitals of 14 (47%) respondents were part of a combination of medical centers that work together in the eld of prostate cancer care. The surgeons originated from all over the world (Table 1). Of the respondents 19 (63%) worked in a ERUS Robotic Certi ed Host centre. *Three respondents were professor, chief and trainer. Two respondents were professor and chief. One respondent was professor and trainer. One respondent was chief and trainer.
The use of postoperative results analysis and surgical video review in daily practice All respondents record surgical videos of their cases. Twenty-seven of the 30 (90%) respondents organized periodical postoperative result analysis meetings, of whom 17 (56%) included surgical video review ( Table 2). One respondent was in the process of including surgical video review in their clinic. The postoperative results analyses were held at various intervals. Two respondents analyzed and reviewed the data alone. Twenty-ve (83%) respondents held the meetings in a team, of which eight only with urology staff, 13 with urology staff and residents, and four held one-on-one meetings. None invited nurses or operating room staff to the review meeting. Different strategies of postoperative results analysis and surgical video review All of the respondents who incorporated video review showed either fast-forwarded or edited videos (i.e. speci c phases of the surgery of fast-forwarded videos). Respondents reported several limitations of video review: lack of storage capacity, lack of structured video database, no structured analysis of videos, lack of time to edit and view videos, and privacy issues. Three respondents reported no limitations and one respondent stated they have staff editing the video material and have extra servers to store video cases. Other respondents would tackle stated limitations by clearing time schedule of staff and residents to view videos, hiring staff to edit videos to only see the relevant frames, creating a structured database with easy storage and acces to videos that meets privacy standards.
All but one respondents (96%) recommended implementation of video review, even those who did not yet practice it. They assumed it improves outcomes through self-re ection, feedback from a colleague who might see details they did not, or from observing different techniques and 'tricks' of a colleague. The participants stated it is important for both residents and staff to take a step back and view their own and others' techniques. It made them realize their limitations and where to focus their improvement. The respondents believe video reviewing improves skills such as dexterity, speed, tissue handling. One respondent who incorporated video reviewing in the training program of residents stated ''Changes [in skills] happen in real time. I see the bene ts of their efforts with each succeeding case.'' The respondents advised similar formats: choose videos of complications or speci c surgical steps, periodically review and discuss these videos in a panel of experts/colleagues or with mentor and residents, be open-minded to feedback and apply the feedback to improve daily clinical practice. Some participants suggested virtual messenger based groups to share short, deidenti ed videos with other experts or to send a video to an expert for reviewing. Future recommendations to improve the video review process were: standardized measurements (de nition of failure), standardized reporting system, relating errors and complications to functional outcomes, relating speci c surgical steps to outcomes. The use of postoperative results analysis and surgical video review in improving daily practice and reduction of complications. All respondents intended to adapt daily practice based on their periodical postoperative results analysis. Two respondents required their urologists and urologists in training to perform RARP under guidance through a dual console Da Vinci robot, either at random or when they do not meet self-constructed quality criteria. Eight respondent (26%) speci cally stated they adapted the surgical approach and postoperative care based on postoperative result analysis, video review and team discussions. They adapted surgical techniques in speci c steps of the surgery, rejected techniques of limited bene t and analyzed the results after a set number of months to create a continuous feedback loop. This has also led to changes in patient selection, due to the fact that some techniques are less suitable for speci c cases. During the meetings, topics of interest were challenging cases (such as patients with high BMI, large prostate volumes), margin status, functional outcomes and surgical complications based on Clavien Dindo classi cation. When assessing functional outcomes, most respondents reviewed those cases with optimal and bad outcomes and compared the surgical techniques on the videos. The reviewed cases had various subjects: outlined surgical complications, salvage treatments, unusual/important ndings or speci c phases of surgery. Factors of interest in postoperative results analysis and surgical video review related to improvement of postoperative functional outcomes and reduction complications Seventeen participants answered the following questions (Table 3). When asked what steps of the RARP possibly in uence postoperative continence, 16 (94%) respondents answered 'management of prostate apex/urethra' and 'urethro-vesical anastomosis.' Fourteen (82%) respondents assumed 'nerve preservation' to in uence recovery of continence. Twelve (71%) thought that 'bladder neck dissection' and 15 (88%) thought that 'urethro-vesical anastomosis' in uences continence. All respondents believed 'neurovascular bundles preservation' and 14 (82%) believed that 'management of prostate apex/urethra' in uences postoperative erectile function. Four (24%) respondents regard 'bladder neck dissection' and 11 (65%) regarded 'ligation of prostate pedicles' as important steps in preservation of erectile function. Factors regarded as being positively or negatively associated with complications and outcomes are represented in Table 4.  In one clinic, case information is presented without identifying the surgeon. In most clinics, feedback on the surgical techniques observed in the videos is given during these meetings.
The use of postoperative results analysis and surgical video review in improving daily practice and reduction of complications.
All surgeons included in this study think surgical video review should be implemented not only for trainees but also as a form of self-re ection for established surgeons. This is in agreement with the results of our previous publication. 1 RARP surgeons feel the implementation of postoperative results analysis and surgical video review could reduce complications and improve outcomes, this is similar to the results of the study by Schlomm et al. 8 and Cathcart et al. 9 . Multiple RARP surgeons use the postoperative results analysis and surgical video review as a manner to evaluate their surgical results and check the effects of changes in surgical approach. Two respondents use a dual console of the robot to perform live reviews of random surgeries as a form of quality assurance.
Factors of interest in postoperative results analysis and surgical video review related to improvement of postoperative functional outcomes and reduction complications Results of the current study may be compared to the results of an earlier Delphi study performed by our group. 1 The results of the current study are in contrast to our earlier study in which 'management of prostate apex/urethra' and 'nerve preservation' are not mentioned as a factor in uencing postoperative urinary continence. 1 In both studies agreement was reached on the role perceived quality of the 'urethrovesical anastomosis' concerning postoperative recovery of urinary continence. 1  A possible in uence to the use of postoperative results analysis and surgical video review in daily practice not raised by the RARP surgeons could be the new and more stringent General Data Protection Regulation (GDPR) in the European Union. 16 Systems should be put in place to assure safe data storage and privacy protection of the patient. Further investigation into the in uence of the new GDRP on the use of postoperative results analysis and surgical video review should be performed. One solution is the anonymization of both surgical video and patient data but this makes correlation of additional follow-up information to the peri-operative data and the surgical video impossible.

Limitations
The relatively low overall response rate (32%) may re ect the interest in this topic in the urological eld.
Whereas the responders were generally positive towards data review, the majority of surveyed centers did not respond. If this observation re ects reduced time availability for data review this is reason for concern given the positive effects of structured data review. The results of this study give the rst insights into the experienced value of postoperative results analysis and surgical video review in the daily practice of RARP surgeons worldwide and a signi cant number of urologists were invited for the survey. Although the experts originated from 15 different countries, the majority of surgeons who completed the questionnaire came from western European country's. Although it is possible that we missed urologists who use postoperative results analysis and surgical video review, we expect that, since the responses of these participants were homogenous, the results in this study represent a near complete overview on the topic. Potentially, 63 more respondents could have given their insight into video review analysis. Two respondents did not fully answer the video review questions.

Suggestions for future research
Although there is some discrepancy between the results of this study and the results of our previous Delphi survey amongst Dutch experts 1 , the results of the present study give additional insights into the acceptance of postoperative results analysis and surgical video review amongst European experts in RARP. The level of detail in the surgical and anatomical factors indicated by the experts gives more insight into which speci c factors experts assume to be associated with surgical complications and negative functional outcomes. This information can give rise to additional elds of research such as the training of arti cial intelligence to recognize surgical errors and events in order to help in the selection of surgical videos for review. Additionally, factors identi ed by the experts could be used to train human observers or Machine learning algorithms to observe and analyze the surgical videos, and to evaluate whether the relation between postoperative outcomes and the factors identi ed by the experts could be objecti ed.

Conclusion
The majority of interviewed RARP surgeons have adopted the implementation of postoperative results analysis and surgical video review in their daily practice as a form of quality assurance and as a form of self-re ection. Since only a minority of surgeons responded to the survey this raises concern on the application of data review in daily practice in non-responders. Most of the responding surgeons use Flow diagram of response.