IU Indianapolis ScholarWorks :: Browsing by Author "Sundaram, Chandru P."

Browsing by Author "Sundaram, Chandru P."

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1- versus 2-Layer Renorrhaphy During Robotic Partial Nephrectomy
(Society of Laparoscopic & Robotic Surgeons, 2025) Yong, Courtney; Sharfuddin, Asif A.; Sundaram, Chandru P.; Bahler, Clinton D.; Urology, School of Medicine
Background and objectives: To determine whether 1- versus 2-layer renorrhaphy affects renal function after partial nephrectomy. Methods: A total of 18 patients undergoing robot-assisted partial nephrectomies for renal tumors at a single center were randomized to 1-layer or 2-layer renorrhaphy. All patients received a running base layer for hemostasis and collecting system closure. The 2-layer renorrhaphy group also underwent cortical closure with running suture, sliding clip method. Demographics and surgical outcomes were collected. Three-dimensional renal models were constructed using semiautomatic segmentation and planimetry pre- and 4 months postsurgery to determine renal volume loss. Welch's t test was used with statistical significance defined as P < .05. Results: Of the 18 patients included in the study, 10 were randomized to 1-layer and 8 to 2-layer renorrhaphy. Demographic variables were matched. There was no difference in postoperative creatinine at 1 month (P = .11), 1 year (P = .28), or 3 years (P = .28) postoperatively. However, the change from pre to postoperative creatinine favored the 1-layer group at 1 month (-0.043 vs +0.11 P = .02) and 3 years (-0.0025 vs 0.244, P = .08) follow up. The 1-layer group had a smaller mean volume loss at 4 months postoperatively compared to the 2-layer group (12% vs 22%, P = .04). Conclusion: This small, randomized trial found increased creatinine and volume loss after 2-layer cortical renorrhaphy. Omitting cortical renorrhaphy may result in better preservation of renal volume and function.
A Comparison of Robotic, Laparoscopic and Open Partial Nephrectomy
(Society of Laparoendoscopic Surgeons, 2012) Lucas, Steven M.; Mellon, Matthew J.; Erntsberger, Luke; Sundaram, Chandru P.; Urology, School of Medicine
Introduction: Comparison of treatments for partial nephrectomy is limited by case selection. We compared robotic (RPN), laparoscopic (LPN), and open partial nephrectomy (OPN), controlling for tumor size, patient age, sex, and nephrometry score. Methods: RPN, LPN, and OPN procedures between March 2003 and March 2010 were reviewed. All RPN and LPN were included, and 2 OPN were matched for each RPN in tumor size (±0.5cm), patient age (±10 y), sex, and nephrometry score. Perioperative outcomes were compared. Results: Ninety-six partial nephrectomy procedures were reviewed: 27 RPN, 15 LPN, and 54 OPN. RPN, LPN, and OPN had similar median tumor size (2.4, 2.2, and 2.3cm, respectively), nephrometry score (6.0 each), and preoperative glomerular filtration rate (71.5, 84.6, and 77.0 mL/min/1.73m(2), respectively). Blood loss was higher for OPN (250 mL) than for RPN or LPN (100 mL), P < 0.001. Operative time was shorter in OPN (147 min) than in RPN (190 min) or LPN (195 min), P < .001. Median warm ischemia time was shorter for OPN (12.0 min) than for RPN (25.0 min) or LPN (29.5 min), P Kt; .05. Cold ischemia time for OPN was 25.0 min. A 10% glomerular filtration rate decline occurred in 10 RPN, 5 LPN, and 29 OPN cases (P < .252). Median hospital stay for LPN and RPN was 2.0 d versus 3.0 d for OPN (P < .001). Urine leak occurred in 1 RPN and 3 OPN cases. Postoperative complications occurred in 4 RPN (3 were Clavien grade 2 or less), 1 LPN (grade 1), and 7 OPN (6 were grade 2 or less) cases. Conclusion: Renal function preservation and complications are similar for each treatment modality. OPN offers faster operative and ischemia times at the expense of greater blood loss and hospital stay.
An Adaptive Human-Robotic Interaction Architecture for Augmenting Surgery Performance Using Real-Time Workload Sensing—Demonstration of a Semi-autonomous Suction Tool
(Sage, 2024) Yang, Jing; Barragan, Juan Antonio; Farrow, Jason Michael; Sundaram, Chandru P.; Wachs, Juan P.; Yu, Denny; Urology, School of Medicine
Objective: This study developed and evaluated a mental workload-based adaptive automation (MWL-AA) that monitors surgeon cognitive load and assist during cognitively demanding tasks and assists surgeons in robotic-assisted surgery (RAS). Background: The introduction of RAS makes operators overwhelmed. The need for precise, continuous assessment of human mental workload (MWL) states is important to identify when the interventions should be delivered to moderate operators' MWL. Method: The MWL-AA presented in this study was a semi-autonomous suction tool. The first experiment recruited ten participants to perform surgical tasks under different MWL levels. The physiological responses were captured and used to develop a real-time multi-sensing model for MWL detection. The second experiment evaluated the effectiveness of the MWL-AA, where nine brand-new surgical trainees performed the surgical task with and without the MWL-AA. Mixed effect models were used to compare task performance, objective- and subjective-measured MWL. Results: The proposed system predicted high MWL hemorrhage conditions with an accuracy of 77.9%. For the MWL-AA evaluation, the surgeons' gaze behaviors and brain activities suggested lower perceived MWL with MWL-AA than without. This was further supported by lower self-reported MWL and better task performance in the task condition with MWL-AA. Conclusion: A MWL-AA systems can reduce surgeons' workload and improve performance in a high-stress hemorrhaging scenario. Findings highlight the potential of utilizing MWL-AA to enhance the collaboration between the autonomous system and surgeons. Developing a robust and personalized MWL-AA is the first step that can be used do develop additional use cases in future studies. Application: The proposed framework can be expanded and applied to more complex environments to improve human-robot collaboration.
An Assessment Tool to Provide Targeted Feedback to Robotic Surgical Trainees: Development and Validation of the End-to-End Assessment of Suturing Expertise (EASE)
(American Urological Association, 2022-11) Haque, Taseen F.; Hui, Alvin; You, Jonathan; Ma, Runzhuo; Nguyen, Jessica H.; Lei, Xiaomeng; Cen, Steven; Aron, Monish; Collins, Justin W.; Djaladat, Hooman; Ghazi, Ahmed; Yates, Kenneth A.; Abreu, Andre L.; Daneshmand, Siamak; Desai, Mihir M.; Goh, Alvin C.; Hu, Jim C.; Lebastchi, Amir H.; Lendvay, Thomas S.; Porter, James; Schuckman, Anne K.; Sotelo, Rene; Sundaram, Chandru P.; Gill, Inderbir S.; Hung, Andrew J.; Urology, School of Medicine
Purpose: To create a suturing skills assessment tool that comprehensively defines criteria around relevant sub-skills of suturing and to confirm its validity. Materials and Methods: 5 expert surgeons and an educational psychologist participated in a cognitive task analysis (CTA) to deconstruct robotic suturing into an exhaustive list of technical skill domains and sub-skill descriptions. Using the Delphi methodology, each CTA element was systematically reviewed by a multi-institutional panel of 16 surgical educators and implemented in the final product when content validity index (CVI) reached ≥0.80. In the subsequent validation phase, 3 blinded reviewers independently scored 8 training videos and 39 vesicourethral anastomoses (VUA) using EASE; 10 VUA were also scored using Robotic Anastomosis Competency Evaluation (RACE), a previously validated, but simplified suturing assessment tool. Inter-rater reliability was measured with intra-class correlation (ICC) for normally distributed values and prevalence-adjusted bias-adjusted Kappa (PABAK) for skewed distributions. Expert (≥100 prior robotic cases) and trainee (<100 cases) EASE scores from the non-training cases were compared using a generalized linear mixed model. Results: After two rounds of Delphi process, panelists agreed on 7 domains, 18 sub-skills, and 57 detailed sub-skill descriptions with CVI ≥ 0.80. Inter-rater reliability was moderately high (ICC median: 0.69, range: 0.51-0.97; PABAK: 0.77, 0.62-0.97). Multiple EASE sub-skill scores were able to distinguish surgeon experience. The Spearman’s rho correlation between overall EASE and RACE scores was 0.635 (p=0.003). Conclusions: Through a rigorous CTA and Delphi process, we have developed EASE, whose suturing sub-skills can distinguish surgeon experience while maintaining rater reliability.
Author's Response JSLS 2006;10:141–144
(Society of Laparoscopic & Robotic Surgeons, 2006) Sundaram, Chandru P.; Urology, School of Medicine
Comparison of Laparoscopy Training Using the Box Trainer Versus the Virtual Trainer
(Society of Laparoscopic & Robotic Surgeons, 2010-04) Mohammadi, Yousef; Lerner, Michelle A.; Sethi, Amanjot S.; Sundaram, Chandru P.; Urology, School of Medicine
Background and Objectives: To evaluate whether training on a virtual reality laparoscopic simulator improves the performance on a laparoscopic box trainer. Methods: Twenty-six subjects were trained using a box trainer, and 17 participants were trained using a virtual simulator. Participants in the experimental group completed 1 session of 5 exercises on the box trainer, 4 sessions on the virtual simulator, and a final session on the box trainer. Participants in the control group completed 6 sessions of 5 exercises on the box trainer alone. Exercises were monitored and scored for time and accuracy. Participants completed a self-evaluation survey after each session and a user satisfaction questionnaire at the end of the training. Results: No significant difference existed between the 2 groups in improvement of accuracy. Pegboard time (P=0.0110) and pattern cutting time (P=0.0229) were the only exercise parameters that improved significantly more in the control group compared with the experimental group. The experimental group developed more interest in a surgical field as a result of their experience than the control group did (70.6% vs 53.8%, respectively). Conclusion: The virtual simulator is a reasonable alternative to the box trainer for laparoscopic skills training.
Comparison of Robot-Assisted Nephrectomy with Laparoscopic and Hand-Assisted Laparoscopic Nephrectomy
(Society of Laparoscopic & Robotic Surgeons, 2010-07) Boger, Michelle; Lucas, Steven M.; Popp, Sara C.; Gardner, Thomas A.; Sundaram, Chandru P.; Urology, School of Medicine
Objective: To compare the initial perioperative outcomes of our robot-assisted laparoscopic nephrectomies with laparoscopic and hand-assisted nephrectomies performed by 2 experienced laparoscopic surgeons. Patients and Methods: We retrospectively evaluated all patients who underwent laparoscopic (LN), hand-assisted (HALN), and robot-assisted laparoscopic nephrectomy (RALN) for benign and malignant diseases between August 2006 and December 2008. Data collected included patient age, body mass index, operative times, estimated blood loss, complications, and hospital stay. Radical nephrectomy was performed for renal neoplasms, and simple nephrectomy was performed for suspected benign diseases. In addition, average direct costs and total costs were calculated for each laparoscopic approach. Results: Forty-six patients underwent LN, 20 underwent HALN, and 13 underwent RALN. The median operative time was 171, 210, and 168 minutes, respectively. LN, HALN, and RALN groups had similar median EBL [(100mL (IQR=113mL), 100mL (IQR=150mL), and 100mL (IQR=125mL); P=0.695], length of hospital stay [2.0d (IQR=1.0d), 3.0d (IQR=2.0d), and 2.0d (IQR=3.0d); P=0.233], and postoperative morphine equivalent analgesic requirements [33mg (IQR=43mg), 45mg (IQR=50mg), and 30mg (IQR=16mg); P=0.766]. Three patients (6%) in the LN group had complications, 2 (10%) in the HALN group had complications, and 4 (30%) in the RALN group had complications. The average total direct operating room costs were $5,500, $6,979, and $6,869 for the LN, HALN, and RALN groups, respectively. Conclusions: Early experience with robotic assistance for radical and simple nephrectomy offers no significant advantage over traditional laparoscopic or hand-assisted approaches. It was also more costly.
Correcting the Shrinkage Effects of Formalin Fixation and Tissue Processing for Renal Tumors: toward Standardization of Pathological Reporting of Tumor Size
(Ivyspring International Publisher, 2015-07-02) Tran, Thu; Sundaram, Chandru P.; Bahler, Clinton D.; Eble, John N.; Gringon, David J.; Monn, M. Francesca; Simper, Novae B.; Cheng, Liang; Department of Pathology and Laboratory Medicine, IU School of Medicine
Given the importance of correctly staging renal cell carcinomas, specific guidelines should be in place for tumor size measurement. While a standard means of renal tumor measurement has not been established, intuitively, tumor size should be based on fresh measurements. We sought to assess the accuracy of postfixation and microscopic measurements of renal tumor size, as compared to fresh measurements and radiographic size. Thirty-four nephrectomy cases performed by a single surgeon were prospectively measured at different time points. The study cases included 23 clear cell renal cell carcinomas, 6 papillary renal cell carcinomas, and 5 other renal tumors. Radiologic tumors were 12.1% larger in diameter than fresh tumors (P<0.01). Furthermore, fresh specimens were 4.6% larger than formalin-fixed specimens (P<0.01), and postfixation measurements were 7.1% greater than microscopic measurements (P<0.01). The overall mean percentage of shrinkage between fresh and histological specimens was 11.4% (P<0.01). Histological processing would cause a tumor stage shift from pT1b to pT1a for two tumors in this study. The shrinkage effects of formalin fixation and histological processing may result in understaging of renal cell carcinomas. The shrinkage factor should be considered when reporting tumor size.
Delaying Cancer Cases in Urology during COVID-19: Review of the Literature
(Wolters Kluwer, 2020-05-28) Tachibana, Isamu; Ferguson, Ethan L.; Mahenthiran, Ashorne; Natarajan, Jay P.; Masterson, Timothy A.; Bahler, Clinton D.; Sundaram, Chandru P.; Urology, School of Medicine
Purpose: Coronavirus Disease 2019 (COVID-19) is a global pandemic affecting hospital systems and the availability of resources for surgical procedures. Our aim is to provide guidance for urologists to help prioritize urologic cancer surgeries. Material and Methods: We reviewed published literature on bladder cancer, upper tract urothelial carcinoma (UTUC), penile cancer, testis cancer, prostate cancer, renal cancer, and adrenal cancer. Results: For muscle invasive bladder cancer (MIBC), delays should be less than roughly 10 weeks and neoadjuvant chemotherapy should be considered. For non-MIBC, patients should be counseled appropriately based on risk and intravesical therapies can continue. UTUC should also be treated with minimal delays for high risk patients, especially with ureteral tumors. Surgery for T1 renal cancers when indicated can be delayed until adequate resources are available. Patients with T2 renal cancer should be considered for early surgery if there are unfavorable pre-operative characteristics. Higher stage renal tumors should be considered for early surgery. Early multi-disciplinary approach is recommended for metastatic renal cancers. High risk prostate cancer may need preferential treatment and consideration of neoadjuvant hormonal therapy. Penile cancer can have worse sexual or oncologic outcome with prolonged surgical delay. Likewise, adrenal cancer is aggressive and needs early surgical treatment. Testicular cancer should be treated in a timely manner with surgery or chemotherapy, as indicated. Conclusions: This review should further assist urologists in recognizing patients with potentially aggressive tumor biology that warrant early treatment.
Delaying Cancer Cases in Urology during COVID-19: Review of the Literature. Reply.
(AUA, 2021-05) Tachibana, Isamu; Sundaram, Chandru P.; Urology, School of Medicine

Browsing by Author "Sundaram, Chandru P."

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