Efficacy and Safety of the “Trisection Method” Training System for Robot-Assisted Radical Cystectomy at a Single Institution in Japan
, Toyohiro Yamada, Risa Tomioka-Inagawa, Fumiya Sugino, Naotaka Kumada, Makoto Kawase, Shinichi Takeuchi, Kota Kawase, Daiki Kato, Manabu Takai, Koji Iinuma and Takuya Koie *
Round 1
Reviewer 1 Report
The authors have reported a "Trisection Method" in Robot-assisted radical cystectomy, in which the operator is rotated at each step. The education of the operator is very important in urological surgery, especially RARC + ICUD, because of the complexity of the process, and the training method is of interest to urological surgeons. Further improvement can be expected in this paper by considering the following points.
1, The authors reported OS and RFS, which appear to be most strongly related to postoperative pathology results. Please show the post-operative pathological results (pT stage, pN stage, etc.) in Table 2.
2, As stated in the Limitation section, the rate of ureterocutaneostomy is extremely high at 39%. Is it because of a patient over the age of 80 with a lot of complications or a suspected upper urinary tract tumor? Or is there another reason?
3, Table 2 shows the total operation time for each operator, but do these include cases in which ICUD was performed by other surgeons?
4, As indicated in Discussion part, a relationship between the learning curve and the number of lymph nodes removed has been reported. How about the number of lymph nodes removed by each surgeon in this study?
Author Response
November 19, 2022
Dr. Editor
The Current oncology
Dear Editor:
Thank you very much for the review of our manuscript titled “Efficacy and Safety of the “Trisection Method” Training System for Robot-Assisted Radical Cystectomy at a Single Institution in Japan.”
We sincerely appreciate all valuable comments and suggestions, which helped us to improve the quality of our manuscript. Our responses to the Reviewers’ comments are described below in a point-to-point manner. Appropriate changes, suggested by the Reviewers, have been introduced to the manuscript (track-changes mode in the red color font). Let me emphasize our full readiness to make any further improvements to the manuscript.
We hope that our manuscript will be acceptable for publication in the Current oncology.
We look forward to hearing from you.
Yours sincerely,
Takuya Koie
Corresponding author
Department of Urology
Gifu University Graduate School of Medicine
1-1 Yanagido, Gifu, Gifu 501-1194, Japan
TEL.: +81-582-30-6338
FAX: +81-582-30-6341
e-mail: [email protected]
Responses to the reviewer's comments
We would like to thank the Reviewers for taking the time and effort necessary to review the manuscript. We sincerely appreciate all the valuable comments and suggestions, which helped us to improve the quality of the manuscript.
Response to Reviewer 1
The authors appreciate the Academic Editor’s comments. The authors’ point-by-point responses to the comments are given below.
- The authors reported OS and RFS, which appear to be most strongly related to postoperative pathology results. Please show the post-operative pathological results (pT stage, pN stage, etc.) in Table 2.
Response:
The authors have added pathological T stage and nodal status in Table 2.
- As stated in the Limitation section, the rate of ureterocutaneostomy is extremely high at 39%. Is it because of a patient over the age of 80 with a lot of complications or a suspected upper urinary tract tumor? Or is there another reason?
Response:
The authors have added the following sentence on line 165:
In this study, ureterocutaneostomy was selected for patients older than 80 years, locally advanced cases with a high risk of recurrence, patients with several comorbidities, and patients with poor general condition. Therefore, the proportion of ureterocutaneostomy was relatively high in the present results.
3, Table 2 shows the total operation time for each operator, but do these include cases in which ICUD was performed by other surgeons?
Response:
The authors have added the following sentence on line 154:
Although comparisons were also performed regarding the total operative time for each generation when a different surgeon underwent the urinary diversion, no significant differences were found among the three groups.
- As indicated in Discussion part, a relationship between the learning curve and the number of lymph nodes removed has been reported. How about the number of lymph nodes removed by each surgeon in this study?
Response:
The authors have added the following sentence on line 256:
According to PLND, there were no significant differences between generations even though the median number of lymph nodes dissected tended to increase gradually with each generation (data not shown).
Author Response File: 
Author Response.docx
Reviewer 2 Report
The study is poor interesting since it replicates what is routinely done in a setting of training for robotic surgery. I don't find any innovation or change by the clinical practice. It is really common to split the surgery in more parts to learn young surgeons. Moreover the Authors don't use the ERUS model that permits a correct evaluation. Once more the study reports small numbers and it manage retrospective model
Author Response
November 19, 2022
Dr. Editor
The Current oncology
Dear Editor:
Thank you very much for the review of our manuscript titled “Efficacy and Safety of the “Trisection Method” Training System for Robot-Assisted Radical Cystectomy at a Single Institution in Japan.”
We sincerely appreciate all valuable comments and suggestions, which helped us to improve the quality of our manuscript. Our responses to the Reviewers’ comments are described below in a point-to-point manner. Appropriate changes, suggested by the Reviewers, have been introduced to the manuscript (track-changes mode in the red color font). Let me emphasize our full readiness to make any further improvements to the manuscript.
We hope that our manuscript will be acceptable for publication in the Current oncology.
We look forward to hearing from you.
Yours sincerely,
Takuya Koie
Corresponding author
Department of Urology
Gifu University Graduate School of Medicine
1-1 Yanagido, Gifu, Gifu 501-1194, Japan
TEL.: +81-582-30-6338
FAX: +81-582-30-6341
e-mail: [email protected]
Responses to the reviewer's comments
We would like to thank the Reviewers for taking the time and effort necessary to review the manuscript. We sincerely appreciate all the valuable comments and suggestions, which helped us to improve the quality of the manuscript.
Response to Reviewer 2
The study is poor interesting since it replicates what is routinely done in a setting of training for robotic surgery. I don't find any innovation or change by the clinical practice. It is really common to split the surgery in more parts to learn young surgeons. Moreover, the Authors don't use the ERUS model that permits a correct evaluation. Once more the study reports small numbers and it manage retrospective model.
Response:
The authors totally agree with your opinion. Currently, there are no high-volume centers like those overseas, and the number of RARC+ICUD cases that can be performed at a single institution is inevitably limited in Japan. Therefore, like the reviewer’s opinions, it is necessary to establish a system to subdivide surgical procedures and to provide efficient surgical education according to RARC followed by ICUD. Also, regarding the teaching of surgery, there is no established
educational system like the ERUS model in Japan. Although the number of enrolled patients is certainly small, we believe that the current educational system is safely passing on surgical skills to the younger generation. Therefore, we believe that this study is significant for institutions with a small number of RARC per year.
The authors have added the following sentence on line 279:
In addition, it seems necessary to establish an educational system for RARC+ICUD, especially in Japan.
Author Response File: Author Response.docx
Reviewer 3 Report
The study has the weaknesses of being a retrospective, single institution study.
Line 19 – “The surgical procedures…” this is redundant with line 14 and 15
Line 40 – “total cystectomy” is not the same as radical cystectomy
Line 45 – “institutional proficiency” should be defined, if possible, taking into consideration the difference between competency and proficiency
Line 56 – “By having different surgeons…” this sentence needs a reference
Line 73 - Defining 1st, 2nd and 3rd generation surgeons does not say anything about their surgical skills and proficiency level. Assuming any of this generations is better or less well trained and or more or less experienced in the procedure is an assumption that cannot be done.
Line 77 – taking time as a metric does not reflect the quality of the surgery
Line 101 – there is no need to write what is the Wallace method
Line 197 – The word “proficiency level” should not be used so lightly, and having performed x number of surgeries does not necessarily translate in better outcomes
Line 240 – reference 28, describes a process, although it still needs to prove its results with clinical data, the e-learning module is not validated, if it really exists, the 5 days of preclinical simulation-based training does not exist, and there is no “proficiency assessment” defined.
Line 265 – the conclusion should be reformulated because it goes from saying “… may be an effective and safe…” to “…can therefore, be replicated…”, meaning that goes from an uncertainty about its effectiveness to a certainty on its replication
Author Response
November 19, 2022
Dr. Editor
The Current oncology
Dear Editor:
Thank you very much for the review of our manuscript titled “Efficacy and Safety of the “Trisection Method” Training System for Robot-Assisted Radical Cystectomy at a Single Institution in Japan.”
We sincerely appreciate all valuable comments and suggestions, which helped us to improve the quality of our manuscript. Our responses to the Reviewers’ comments are described below in a point-to-point manner. Appropriate changes, suggested by the Reviewers, have been introduced to the manuscript (track-changes mode in the red color font). Let me emphasize our full readiness to make any further improvements to the manuscript.
We hope that our manuscript will be acceptable for publication in the Current oncology.
We look forward to hearing from you.
Yours sincerely,
Takuya Koie
Corresponding author
Department of Urology
Gifu University Graduate School of Medicine
1-1 Yanagido, Gifu, Gifu 501-1194, Japan
TEL.: +81-582-30-6338
FAX: +81-582-30-6341
e-mail: [email protected]
Responses to the reviewer's comments
We would like to thank the Reviewers for taking the time and effort necessary to review the manuscript. We sincerely appreciate all the valuable comments and suggestions, which helped us to improve the quality of the manuscript.
Response to Reviewer 3
The authors appreciate the Academic Editor’s comments. The authors’ point-by-point responses to the comments are given below.
- Line 19 - “The surgical procedures…” this is redundant with line 14 and 15
Response:
The authors have deleted the following sentence on line 19:
The surgical procedures were performed in three parts: RARC, bowel reconstruction, and ICUD.
- Line 40 - “total cystectomy” is not the same as radical cystectomy
Response:
The authors have changed from "total" to "radical” on line 40.
- Line 45 -“institutional proficiency” should be defined, if possible, taking into consideration the difference between competency and proficiency
Response:
The authors have added the following part on line 46:
proficiency, including anesthesiologists, operating room nurses, clinical engineers, and other surgical staff, should be taken into
- Line 56 - “By having different surgeons…” this sentence needs a reference
Response:
The authors have added the following citations on line 61:
separately to the next generation surgeon [14,15].
The authors added the following refrrence:
- Filson, C.P.; Tan, H.J.; Chamie, K.; Laviana, A.A.; Hu, J.C. Determinants of radical cystectomy operative time. Urol Oncol. 2016, 34, 431.e17-24.
- Line 73 - Defining 1st, 2nd and 3rd generation surgeons does not say anything about their surgical skills and proficiency level. Assuming any of this generations is better or less well trained and or more or less experienced in the procedure is an assumption that cannot be done.
Response:
The authors have added the following sentences on line 193:
Certainly, it is difficult to accurately assess the level of surgical technique of each generation in this study. However, the purpose of this study was not to compare which generation's surgical technique was superior; the objective was to verify whether the RARC+ICUD technique was correctly and safely passed on from surgeons already performing it safely to the next generation of surgeons. Therefore, perioperative outcomes, oncologic outcomes, and complication rates were compared between each generation.
- Line 77 - taking time as a metric does not reflect the quality of the surgery
Response:
The authors have added the following sentences on line 199:
Regarding the quality of surgery, it may be important to consider indicators such as negative resection margins and a low incidence of postoperative complications. However, there are concerns that longer operative time may result in increased blood loss, increased cardiopulmonary burden due to the Trendelenburg position, and increased incidence of compartment syndrome. Therefore, analysis of operative time and length of hospital stay would be meaningful as a method to assure the quality of surgery.
- Line 101 - there is no need to write what is the Wallace method
Response:
The authors have deleted the following part on line 104:
The Wallace method was used for creating an intracorporeal ileal conduit, which is the anastomosis between the ureter and ileum [14].
- Line 197 - The word “proficiency level” should not be used so lightly, and having performed x number of surgeries does not necessarily translate in better outcomes
Response:
The authors have deleted the following sentence on line 216:
Therefore, as a surrogate indicator of RARC quality, they concluded that having performed ≥30 surgeries demonstrated an acceptable proficiency level [19].
- Line 240 - reference 28, describes a process, although it still needs to prove its results with clinical data, the e-learning module is not validated, if it really exists, the 5 days of preclinical simulation-based training does not exist, and there is no “proficiency assessment” defined.
Response:
The authors have revised the following sentences on line 256:
clinical modular training, and finally a proficiency assessment [29]. Although this training model has not yet been validated, it was developed with opinions from RARC experts, and its effectiveness may need to be further tested in the future.
- Line 265 – the conclusion should be reformulated because it goes from saying “… may be an effective and safe…” to “…can therefore, be replicated…”, meaning that goes from an uncertainty about its effectiveness to a certainty on its replication
Response:
The authors have revised the following part on line 288:
and can therefore, be it may be possible to replicated
Author Response File: Author Response.docx
Round 2
Reviewer 1 Report
The authors addressed reviewers' comments in the revised version.
Reviewer 2 Report
The paper has been changed with adequate replay.
