Surgeon Automated Performance Metrics as Predictors of Early Urinary Continence Recovery After Robotic Radical Prostatectomy—A Prospective Bi-institutional Study

BACKGROUND: During robotic surgeries, kinematic metrics objectively quantify surgeon performance. OBJECTIVE: To determine whether clinical factors confound the ability of surgeon performance metrics to anticipate urinary continence recovery after robot-assisted radical prostatectomies (RARPs). DESIGN, SETTING, AND PARTICIPANTS: Clinical data (patient characteristics, continence recovery, and treatment factors) and surgeon data from RARPs performed between July 2016 and November 2018 were prospectively collected. Surgeon data included 40 automated performance metrics (APMs) derived from robot systems (instrument kinematics and events) and summarized over each standardized RARP step. The data were collected from two high-volume robotic centers in the USA and Germany. Surgeons from both institutions performed RARPs. The inclusion criteria were consecutive RARPs having both clinical and surgeon data. INTERVENTION: RARP with curative intent to treat prostate cancer. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The outcome was 3- and 6-mo urinary continence recovery status. Continence was defined as the use of zero or one safety pad per day. Random forest (SAS HPFOREST) was utilized. RESULTS AND LIMITATIONS: A total of 193 RARPs performed by 20 surgeons were included. Of the patients, 56.7% (102/180) and 73.3% (129/176) achieved urinary continence by 3 and 6 mo after RARP, respectively. The model anticipated continence recovery (area under the curve = 0.74, 95% confidence interval [CI] 0.66–0.81 for 3-mo, and area under the curve = 0.67, 95% CI 0.58–0.76 for 6 mo). Clinical factors, including pT stage, confounded APMs during prediction of continence recovery at 3 mo after RARP (Δβ median –13.3%, interquartile range [–28.2% to –6.5%]). After adjusting for clinical factors, 11/20 (55%) top-ranking APMs remained significant and independent predictors (ie, velocity and wrist articulation during the vesicourethral anastomosis). Limitations included heterogeneity of surgeon/patient data between institutions, although it was accounted for during multivariate analysis. CONCLUSIONS: Clinical factors confound surgeon performance metrics during the prediction of urinary continence recovery after RARP. Nonetheless, many surgeon factors are still independent predictors of early continence recovery. PATIENT SUMMARY: Both patient factors and surgeon kinematic metrics, recorded during robotic prostatectomies, impact early urinary continence recovery after robot-assisted radical prostatectomy.