{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,3,31]],"date-time":"2026-03-31T22:14:23Z","timestamp":1774995263670,"version":"3.50.1"},"reference-count":31,"publisher":"Springer Science and Business Media LLC","issue":"1","license":[{"start":{"date-parts":[[2022,12,22]],"date-time":"2022-12-22T00:00:00Z","timestamp":1671667200000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"},{"start":{"date-parts":[[2022,12,22]],"date-time":"2022-12-22T00:00:00Z","timestamp":1671667200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"}],"funder":[{"DOI":"10.13039\/100000054","name":"U.S. Department of Health & Human Services | NIH | National Cancer Institute","doi-asserted-by":"publisher","award":["R01CA273031"],"award-info":[{"award-number":["R01CA273031"]}],"id":[{"id":"10.13039\/100000054","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["link.springer.com"],"crossmark-restriction":false},"short-container-title":["npj Digit. Med."],"abstract":"<jats:title>Abstract<\/jats:title><jats:p>How well a surgery is performed impacts a patient\u2019s outcomes; however, objective quantification of performance remains an unsolved challenge. Deconstructing a procedure into discrete instrument-tissue \u201cgestures\u201d is a emerging way to understand surgery. To establish this paradigm in a procedure where performance is the most important factor for patient outcomes, we identify 34,323 individual gestures performed in 80 nerve-sparing robot-assisted radical prostatectomies from two international medical centers. Gestures are classified into nine distinct dissection gestures (e.g., hot cut) and four supporting gestures (e.g., retraction). Our primary outcome is to identify factors impacting a patient\u2019s 1-year erectile function (EF) recovery after radical prostatectomy. We find that less use of hot cut and more use of peel\/push are statistically associated with better chance of 1-year EF recovery. Our results also show interactions between surgeon experience and gesture types\u2014similar gesture selection resulted in different EF recovery rates dependent on surgeon experience. To further validate this framework, two teams independently constructe distinct machine learning models using gesture sequences vs. traditional clinical features to predict 1-year EF. In both models, gesture sequences are able to better predict 1-year EF (Team 1: AUC 0.77, 95% CI 0.73\u20130.81; Team 2: AUC 0.68, 95% CI 0.66\u20130.70) than traditional clinical features (Team 1: AUC 0.69, 95% CI 0.65\u20130.73; Team 2: AUC 0.65, 95% CI 0.62\u20130.68). Our results suggest that gestures provide a granular method to objectively indicate surgical performance and outcomes. Application of this methodology to other surgeries may lead to discoveries on methods to improve surgery.<\/jats:p>","DOI":"10.1038\/s41746-022-00738-y","type":"journal-article","created":{"date-parts":[[2022,12,22]],"date-time":"2022-12-22T08:03:51Z","timestamp":1671696231000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":49,"title":["Surgical gestures as a method to quantify surgical performance and predict patient outcomes"],"prefix":"10.1038","volume":"5","author":[{"given":"Runzhuo","family":"Ma","sequence":"first","affiliation":[]},{"given":"Ashwin","family":"Ramaswamy","sequence":"additional","affiliation":[]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4093-2315","authenticated-orcid":false,"given":"Jiashu","family":"Xu","sequence":"additional","affiliation":[]},{"given":"Loc","family":"Trinh","sequence":"additional","affiliation":[]},{"given":"Dani","family":"Kiyasseh","sequence":"additional","affiliation":[]},{"given":"Timothy N.","family":"Chu","sequence":"additional","affiliation":[]},{"given":"Elyssa Y.","family":"Wong","sequence":"additional","affiliation":[]},{"given":"Ryan S.","family":"Lee","sequence":"additional","affiliation":[]},{"given":"Ivan","family":"Rodriguez","sequence":"additional","affiliation":[]},{"given":"Gina","family":"DeMeo","sequence":"additional","affiliation":[]},{"given":"Aditya","family":"Desai","sequence":"additional","affiliation":[]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6979-6316","authenticated-orcid":false,"given":"Maxwell X.","family":"Otiato","sequence":"additional","affiliation":[]},{"given":"Sidney I.","family":"Roberts","sequence":"additional","affiliation":[]},{"given":"Jessica H.","family":"Nguyen","sequence":"additional","affiliation":[]},{"given":"Jasper","family":"Laca","sequence":"additional","affiliation":[]},{"given":"Yan","family":"Liu","sequence":"additional","affiliation":[]},{"given":"Katarina","family":"Urbanova","sequence":"additional","affiliation":[]},{"given":"Christian","family":"Wagner","sequence":"additional","affiliation":[]},{"given":"Animashree","family":"Anandkumar","sequence":"additional","affiliation":[]},{"given":"Jim C.","family":"Hu","sequence":"additional","affiliation":[]},{"ORCID":"https:\/\/orcid.org\/0000-0002-7201-6736","authenticated-orcid":false,"given":"Andrew J.","family":"Hung","sequence":"additional","affiliation":[]}],"member":"297","published-online":{"date-parts":[[2022,12,22]]},"reference":[{"key":"738_CR1","doi-asserted-by":"publisher","first-page":"1434","DOI":"10.1056\/NEJMsa1300625","volume":"369","author":"JD Birkmeyer","year":"2013","unstructured":"Birkmeyer, J. D. et al. Surgical skill and complication rates after bariatric surgery. N. Engl. J. Med. 369, 1434\u20131442 (2013).","journal-title":"N. Engl. J. Med."},{"key":"738_CR2","doi-asserted-by":"publisher","first-page":"492","DOI":"10.1097\/SLA.0000000000001959","volume":"265","author":"AB Fecso","year":"2017","unstructured":"Fecso, A. B., Szasz, P., Kerezov, G. & Grantcharov, T. P. The effect of technical performance on patient outcomes in surgery: a systematic review. Ann. Surg. 265, 492\u2013501 (2017).","journal-title":"Ann. Surg."},{"key":"738_CR3","doi-asserted-by":"publisher","first-page":"1059","DOI":"10.1001\/jamasurg.2021.3651","volume":"156","author":"AJ Hung","year":"2021","unstructured":"Hung, A. J., Liu, Y. & Anandkumar, A. Deep learning to automate technical skills assessment in robotic surgery. JAMA Surg. 156, 1059 (2021).","journal-title":"JAMA Surg."},{"key":"738_CR4","doi-asserted-by":"publisher","first-page":"4918","DOI":"10.1007\/s00464-021-08578-9","volume":"35","author":"OR Meireles","year":"2021","unstructured":"Meireles, O. R. et al. SAGES consensus recommendations on an annotation framework for surgical video. Surg. Endosc. 35, 4918\u20134929 (2021).","journal-title":"Surg. Endosc."},{"key":"738_CR5","doi-asserted-by":"publisher","first-page":"271","DOI":"10.1097\/JU.0000000000001328","volume":"205","author":"R Ma","year":"2021","unstructured":"Ma, R. et al. A novel dissection gesture classification to characterize robotic dissection technique for renal hilar dissection. J. Urol. 205, 271\u2013275 (2021).","journal-title":"J. Urol."},{"key":"738_CR6","doi-asserted-by":"publisher","first-page":"7","DOI":"10.3322\/caac.21708","volume":"72","author":"RL Siegel","year":"2022","unstructured":"Siegel, R. L., Miller, K. D., Fuchs, H. E. & Jemal, A. Cancer statistics, 2022. CA Cancer J. Clin. 72, 7\u201333 (2022).","journal-title":"CA Cancer J. Clin."},{"key":"738_CR7","doi-asserted-by":"publisher","first-page":"1901","DOI":"10.1001\/jama.2018.3710","volume":"319","author":"US Preventive Services Task Force.","year":"2018","unstructured":"US Preventive Services Task Force. et al. Screening for Prostate Cancer: US Preventive Services Task Force Recommendation Statement. JAMA 319, 1901\u20131913 (2018).","journal-title":"JAMA"},{"key":"738_CR8","doi-asserted-by":"publisher","unstructured":"Basourakos, S. P. et al. Robot-assisted radical prostatectomy maneuvers to attenuate erectile dysfunction: technical description and video compilation. J. Endourol. https:\/\/doi.org\/10.1089\/end.2021.0081 (2021).","DOI":"10.1089\/end.2021.0081"},{"key":"738_CR9","doi-asserted-by":"publisher","first-page":"317","DOI":"10.1016\/j.eururo.2010.10.045","volume":"59","author":"A Vickers","year":"2011","unstructured":"Vickers, A. et al. Cancer control and functional outcomes after radical prostatectomy as markers of surgical quality: analysis of heterogeneity between surgeons at a single cancer center. Eur. Urol. 59, 317\u2013322 (2011).","journal-title":"Eur. Urol."},{"key":"738_CR10","doi-asserted-by":"publisher","first-page":"65","DOI":"10.1016\/j.ucl.2021.07.009","volume":"49","author":"AB Chen","year":"2022","unstructured":"Chen, A. B. et al. Artificial intelligence applications in urology: reporting standards to achieve fluency for urologists. Urol. Clin. 49, 65\u2013117 (2022).","journal-title":"Urol. Clin."},{"key":"738_CR11","doi-asserted-by":"publisher","first-page":"749","DOI":"10.1038\/nrclinonc.2017.141","volume":"14","author":"P Lambin","year":"2017","unstructured":"Lambin, P. et al. Radiomics: the bridge between medical imaging and personalized medicine. Nat. Rev. Clin. Oncol. 14, 749\u2013762 (2017).","journal-title":"Nat. Rev. Clin. Oncol."},{"key":"738_CR12","doi-asserted-by":"publisher","first-page":"586","DOI":"10.1089\/end.2006.20.586","volume":"20","author":"TE Ahlering","year":"2006","unstructured":"Ahlering, T. E., Skarecky, D. & Borin, J. Impact of cautery versus cautery-free preservation of neurovascular bundles on early return of potency. J. Endourol. 20, 586\u2013589 (2006).","journal-title":"J. Endourol."},{"key":"738_CR13","doi-asserted-by":"publisher","unstructured":"Inouye, D. A. et al. Assessing the efficacy of dissection gestures in robotic surgery. J. Robotic. Surg. https:\/\/doi.org\/10.1007\/s11701-022-01458-x (2022).","DOI":"10.1007\/s11701-022-01458-x"},{"key":"738_CR14","doi-asserted-by":"publisher","first-page":"596","DOI":"10.1097\/UPJ.0000000000000246","volume":"8","author":"EB Vanstrum","year":"2021","unstructured":"Vanstrum, E. B. et al. Development and validation of an objective scoring tool to evaluate surgical dissection: dissection assessment for robotic technique (DART). Urol. Pract. 8, 596\u2013604 (2021).","journal-title":"Urol. Pract."},{"key":"738_CR15","doi-asserted-by":"publisher","first-page":"3261","DOI":"10.1007\/s00464-015-4070-8","volume":"29","author":"MA Aghazadeh","year":"2015","unstructured":"Aghazadeh, M. A. et al. External validation of Global Evaluative Assessment of Robotic Skills (GEARS). Surg. Endosc. 29, 3261\u20133266 (2015).","journal-title":"Surg. Endosc."},{"key":"738_CR16","doi-asserted-by":"publisher","first-page":"247","DOI":"10.1016\/j.juro.2011.09.032","volume":"187","author":"AC Goh","year":"2012","unstructured":"Goh, A. C., Goldfarb, D. W., Sander, J. C., Miles, B. J. & Dunkin, B. J. Global evaluative assessment of robotic skills: validation of a clinical assessment tool to measure robotic surgical skills. J. Urol. 187, 247\u2013252 (2012).","journal-title":"J. Urol."},{"key":"738_CR17","doi-asserted-by":"publisher","DOI":"10.1007\/s11934-021-01043-z","volume":"22","author":"R Ma","year":"2021","unstructured":"Ma, R., Reddy, S., Vanstrum, E. B. & Hung, A. J. Innovations in urologic surgical training. Curr. Urol. Rep. 22, 26 (2021).","journal-title":"Curr. Urol. Rep."},{"key":"738_CR18","doi-asserted-by":"publisher","first-page":"296","DOI":"10.1016\/j.juro.2017.07.081","volume":"199","author":"AJ Hung","year":"2018","unstructured":"Hung, A. J. et al. Development and validation of objective performance metrics for robot-assisted radical prostatectomy: a pilot study. J. Urol. 199, 296\u2013304 (2018).","journal-title":"J. Urol."},{"key":"738_CR19","doi-asserted-by":"publisher","first-page":"770","DOI":"10.1001\/jamasurg.2018.1512","volume":"153","author":"AJ Hung","year":"2018","unstructured":"Hung, A. J., Chen, J. & Gill, I. S. Automated performance metrics and machine learning algorithms to measure surgeon performance and anticipate clinical outcomes in robotic surgery. JAMA Surg. 153, 770\u2013771 (2018).","journal-title":"JAMA Surg."},{"key":"738_CR20","doi-asserted-by":"publisher","first-page":"438","DOI":"10.1089\/end.2018.0035","volume":"32","author":"AJ Hung","year":"2018","unstructured":"Hung, A. J. et al. Utilizing machine learning and automated performance metrics to evaluate robot-assisted radical prostatectomy performance and predict outcomes. J. Endourol. 32, 438\u2013444 (2018).","journal-title":"J. Endourol."},{"key":"738_CR21","doi-asserted-by":"crossref","unstructured":"Ma, R. et al. Tailored feedback based on clinically relevant performance metrics expedites the acquisition of robotic suturing skills\u2014an unblinded pilot randomized controlled trial. J. Urol. 208, 414\u2013424 (2022).","DOI":"10.1097\/JU.0000000000002691"},{"key":"738_CR22","doi-asserted-by":"publisher","first-page":"861","DOI":"10.1111\/bju.14599","volume":"123","author":"AJ Hung","year":"2019","unstructured":"Hung, A. J. et al. Experts vs super-experts: differences in automated performance metrics and clinical outcomes for robot-assisted radical prostatectomy. BJU Int. 123, 861\u2013868 (2019).","journal-title":"BJU Int."},{"key":"738_CR23","doi-asserted-by":"crossref","unstructured":"Bhat K. R. S. et al. A predictive pre- and post-operative nomogram for post-operative potency recovery after robot-assisted radical prostatectomy. J. Urol. 206, 942\u2013951 (2021).","DOI":"10.1097\/JU.0000000000001895"},{"key":"738_CR24","doi-asserted-by":"publisher","first-page":"1796","DOI":"10.1016\/j.jsxm.2019.08.003","volume":"16","author":"JP Mulhall","year":"2019","unstructured":"Mulhall, J. P. et al. Development of nomograms to predict the recovery of erectile function following radical prostatectomy. J. Sex. Med. 16, 1796\u20131802 (2019).","journal-title":"J. Sex. Med."},{"key":"738_CR25","unstructured":"Kiyasseh, D. et al. Quantification of robotic surgeries with vision-based deep learning. Preprint at https:\/\/arxiv.org\/abs\/2205.03028 (2022)."},{"key":"738_CR26","doi-asserted-by":"publisher","first-page":"760","DOI":"10.1016\/j.juro.2017.02.3344","volume":"198","author":"LN Nguyen","year":"2017","unstructured":"Nguyen, L. N. et al. The risks and benefits of cavernous neurovascular bundle sparing during radical prostatectomy: a systematic review and meta-analysis. J. Urol. 198, 760\u2013769 (2017).","journal-title":"J. Urol."},{"key":"738_CR27","doi-asserted-by":"publisher","first-page":"617","DOI":"10.1111\/bju.12315","volume":"114","author":"H Abboudi","year":"2014","unstructured":"Abboudi, H. et al. Learning curves for urological procedures: a systematic review. BJU Int. 114, 617\u2013629 (2014).","journal-title":"BJU Int."},{"key":"738_CR28","doi-asserted-by":"publisher","first-page":"307","DOI":"10.1038\/sj.ijir.3901327","volume":"17","author":"JC Cappelleri","year":"2005","unstructured":"Cappelleri, J. C. & Rosen, R. C. The Sexual Health Inventory for Men (SHIM): a 5-year review of research and clinical experience. Int. J. Impot Res. 17, 307\u2013319 (2005).","journal-title":"Int. J. Impot Res."},{"key":"738_CR29","doi-asserted-by":"publisher","first-page":"373","DOI":"10.1111\/anae.14569","volume":"74","author":"D Mayhew","year":"2019","unstructured":"Mayhew, D., Mendonca, V. & Murthy, B. V. S. A review of ASA physical status\u2014historical perspectives and modern developments. Anaesthesia 74, 373\u2013379 (2019).","journal-title":"Anaesthesia"},{"key":"738_CR30","unstructured":"Vaswani, A. et al. Attention is All you Need. In Advances in Neural Information Processing Systems vol. 30 (Curran Associates, Inc., 2017)."},{"key":"738_CR31","unstructured":"Gorishniy, Y., Rubachev, I., Khrulkov, V. & Babenko, A. Revisiting deep learning models for tabular data. https:\/\/arxiv.org\/abs\/2106.11959 (2021)."}],"container-title":["npj Digital Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.nature.com\/articles\/s41746-022-00738-y.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/www.nature.com\/articles\/s41746-022-00738-y","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/www.nature.com\/articles\/s41746-022-00738-y.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2022,12,22]],"date-time":"2022-12-22T08:03:54Z","timestamp":1671696234000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.nature.com\/articles\/s41746-022-00738-y"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2022,12,22]]},"references-count":31,"journal-issue":{"issue":"1","published-online":{"date-parts":[[2022,12]]}},"alternative-id":["738"],"URL":"https:\/\/doi.org\/10.1038\/s41746-022-00738-y","relation":{},"ISSN":["2398-6352"],"issn-type":[{"value":"2398-6352","type":"electronic"}],"subject":[],"published":{"date-parts":[[2022,12,22]]},"assertion":[{"value":"30 August 2022","order":1,"name":"received","label":"Received","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"29 November 2022","order":2,"name":"accepted","label":"Accepted","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"22 December 2022","order":3,"name":"first_online","label":"First Online","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"C.W. declares no competing non-financial interests but reports financial disclosures with Intuitive Surgical, Inc. A.A. declares no competing non-financial interests but is a paid employee of Nvidia. J.C.H. declares no competing non-financial interests but the following competing financial interests: salary support from the Frederick J. and Theresa Dow Wallace Fund of the New York and from Prostate Cancer Foundation Challenge Award. Also salary support from NIH R01 CA241758 and R01 CA259173, PCORI CER-2019C1-15682 and CER-2019C2-17372. A.J.H. declares no competing non-financial interests but reports financial disclosures with Intuitive Surgical, Inc. The remaining authors declare no competing interests.","order":1,"name":"Ethics","group":{"name":"EthicsHeading","label":"Competing interests"}}],"article-number":"187"}}