355 Summary stump length measured during surgery and postoperative continence of the patient. The difference in results compared to the study of Bautista Vidal, et al who did not find a relation between the length of the urethral stump and postoperative continence status of the patient could be due to a different method of measurement during surgery.60 If the technique can be adapted to be used during surgery and not only in the pre-recorded surgical video’s a new surgical challenge will be to save as much urethral length as possible during RARP. Additional research is needed to determine the ideal urethral length for achieving continence. If there is such an ideal urethral length, surgical procedure could be adjusted to standardise the dissection and mobilisation of parts of the prostatic urethra to increase urethral stump length and increase the chances of continence of the patient. The PACE42, the GEARS43, and the PROTEST assessment methods used in chapter 9 and chapter 10 are time-consuming ways of assessing surgeons’ skills. Since these methods are based on human review, subjective bias cannot be avoided, leading to reduced interrater reliability. To objectify the assessment and to reduce the time investment of ‘manual assessment’ by the observer automated assessment tools are being studied.64,65 Recently, Hung et al. investigated the possibility of the analysis of the movements of the surgical robot with the dVLogger system which led to greater insight into the performance of the surgeons and could be used to predict postoperative outcomes.64,66 The dVLlogger system automatically logs motion tracking and system events data in live surgeries. This leaves large datasets and pre-recorded surgical video stock piles useless in this type of research. In chapter 12, we investigate the possibility to automatically assess instrument movements in pre-recorded videos of RARP patients to find if the movements of surgical instruments predict functional outcome of the surgery. The Kinovea software can automatically track instrument movements in laparoscopic surgery without requiring additional equipment.65 The results presented in chapter 12 show the speed of the surgical instruments, tissue overlapping the instrument and the fact that the instrument has flexible joints, makes it impossible to track the instrument movements in pre-recorded RARP videos. Further research with larger groups of patients and a different automated tracking system is needed to investigate the possibility of automated surgical movement assessment in pre-recorded surgical videos. In Chapter 13 the main findings of the different studies in this thesis are discussed. The answers to the two main research questions were formulated in an overall conclusion. Methodological considerations are given and recommendations for future research are presented.
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