Kenneth Chen

Background: Adoption of surgical robotic systems is accelerating globally, driven by advances in clinical capability, ergonomics, and workflow efficiency. However, robotic surgery programs introduce complex organizational challenges related to patient safety, workforce capability, infrastructure readiness, governance, vendor dependency, procurement, and long-term sustainability. Hospitals often lack structured, leadership-oriented frameworks to support systematic, context-appropriate evaluation, adoption, and governance of these technologies. Objective: To develop a multidisciplinary, consensus-based framework to support leadership-level evaluation, organizational readiness assessment, adoption, and governance of surgical robotic systems. Methods: A two-round modified Delphi study was conducted at Singapore General Hospital involving eleven stakeholder groups spanning clinical, perioperative, technical, operational, governance, and executive domains. Department-level consensus responses were generated. In Round 1, stakeholders completed role-specific questionnaires comprising Likert-scale items and open-ended questions. Items rated as low importance were excluded, while items of moderate importance were refined through thematic analysis. In Round 2, refined and newly generated items were re-evaluated. Items achieving ≥70% agreement for high importance within each stakeholder group were retained. Results: A total of 417 consensus-derived items were identified and organized into nine thematic domains encompassing patient safety and risk management, technical capability and surgical performance, workflow integration, training and credentialing, governance and sustainability, vendor support, infrastructure, logistics, and operational readiness. The framework was operationalized through category-specific interpretive scoring rubrics and three domain-weighted decision models reflecting clinician, safety, and procurement perspectives. Conclusions: This study presents a leadership-oriented, multi-stakeholder framework to support the risk-aware evaluation, adoption, implementation, and governance of surgical robotic systems. By integrating considerations across institutional readiness, comparative robotic platform assessment, and program governance, the framework provides a structured approach to decision-making throughout the robotic surgery lifecycle. While it may serve as a useful starting point for institutions seeking to establish or expand robotic surgery programs, the framework was developed and evaluated within a single academic tertiary healthcare institution. Further validation across diverse healthcare settings, including community hospitals, non-academic institutions, specialty centers, and resource-constrained environments, is required before broader adoption can be recommended.

Background: Evidence for neoadjuvant androgen deprivation therapy (ADT) before radical prostatectomy (RP) remains inconclusive, and current guidelines do not endorse its routine use. Objective: We aimed to evaluate the impact of neoadjuvant ADT on surgical and oncologic outcomes in a Singaporean cohort undergoing radical prostatectomy. Design, setting, and participants: In this retrospective study, 1091 men underwent RP between 2013 and 2024; a total of 105 received neoadjuvant ADT and 986 did not. A 1:1 propensity score-matched analysis was performed on age, PSA, PSA density, Gleason score, clinical T-stage, and receipt of adjuvant therapies, yielding 105 matched pairs. Outcome measurements and statistical analysis: The primary outcome was biochemical recurrence (BCR). Secondary surgical outcomes included operative time, estimated blood loss, length of stay, catheter duration, and postoperative complications. Secondary oncologic outcomes included extracapsular extension, margin status, seminal vesicle invasion, lymph node involvement, clinical-to-pathological T-stage downstaging, Gleason score decrease, and PSA decrease. Kaplan–Meier survival and univariable linear and logistic regression analyses were used. Subgroup analysis was performed using stratified odds ratios to identify clinical subgroups that derived the greatest benefit from neoadjuvant ADT in terms of biochemical recurrence reduction. Results and limitations: After matching, neoadjuvant ADT was associated with a lower rate of extracapsular extension (30.8% vs. 51.4%, p = 0.004), positive surgical margins (18.4% vs. 39.4%, p = 0.002), lymph node involvement (1.0% vs. 13.0%, p = 0.002), and biochemical recurrence (4.8% vs. 18.1%, p = 0.005). There were no significant differences in operative time, blood loss, length of stay, or complication rates. Before matching, 2-year biochemical recurrence-free survival (BCR-FS) did not differ significantly (93.0% vs. 88.2%, log-rank p = 0.26), but after matching, BCR-FS favored ADT (93.0% vs. 81.8%, log-rank p = 0.02). Subgroup analysis showed that the reduction in biochemical recurrence with neoadjuvant ADT was more pronounced in patients with PSA density ≥ 0.20 ng/mL², Gleason score ≥ 8, and clinical T3 disease. Limitations include the retrospective design and potential residual confounding. Conclusions: Neoadjuvant ADT prior to RP significantly reduces locoregional spread and biochemical recurrence without increasing perioperative morbidity. Prospective trials are needed to confirm its benefit in high-risk prostate cancer.

Background: Prostate-specific antigen (PSA) testing remains the cornerstone of early prostate cancer detection. Society guidelines for prostate cancer screening via PSA testing serve to standardize patient care and are often used by trainees, junior staff, or generalist medical practitioners to guide medical decision-making. However, adherence to guidelines is a time-consuming and challenging task, and rates of inappropriate PSA testing are high. Retrieval-augmented generation (RAG) is a method to enhance the reliability of large language models (LLMs) by grounding responses in trusted external sources. Objective: This study aimed to evaluate a RAG-enhanced LLM system, grounded in current European Association of Urology and American Urological Association guidelines, to assess its effectiveness in providing guideline-concordant PSA screening recommendations compared to junior clinicians. Methods: A series of 44 fictional outpatient case scenarios was developed to represent a broad spectrum of clinical presentations. A RAG pipeline was developed, comprising a life expectancy estimation module based on the Charlson Comorbidity Index, followed by LLM-generated recommendations constrained to retrieved excerpts from the European Association of Urology and American Urological Association guidelines. Five junior clinicians were tasked to provide PSA testing recommendations for the same scenarios in closed-book and open-book formats. Answers were compared for accuracy in a binomial fashion. Fleiss κ was computed to assess interrater agreement among clinicians. Results: The RAG-LLM tool provided guideline-concordant recommendations in 95.5% (210/220) of case scenarios, compared to junior clinicians, who were correct in 62.3% (220) of scenarios in a closed-book format and 74.1% (220) of scenarios in an open-book format. The difference was statistically significant for both closed-book ( P <.001) and open-book ( P <.001) formats. Interrater agreement among clinicians was fair, with Fleiss κ of 0.294 and 0.321 for closed-book and open-book formats, respectively. Conclusions: Use of RAG techniques allows LLMs to integrate complex guidelines into day-to-day medical decision-making. RAG-LLM tools in urology have the capability to enhance clinical decision-making by providing guideline-concordant recommendations for PSA testing, potentially improving the consistency of health care delivery, reducing cognitive load on clinicians, and reducing unnecessary investigations and costs. While this study used synthetic cases in a controlled simulation environment, it establishes a foundation for future validation in real-world clinical settings.

Robotic surgery has revolutionized modern surgical practices, expanding across multiple specialties due to its precision, reduced invasiveness, and improved patient outcomes. Initially dominated by the da Vinci system, the field has recently seen an influx of new robotic platforms, presenting challenges in training and adaptation for surgeons and surgical teams. The transition to diverse robotic systems necessitates a structured educational framework to ensure competency across varying platforms. This article explores the evolving landscape of robotic surgery, emphasizing the need for a comprehensive training methodology. A qualitative analysis of expert and novice perspectives identified three key domains for robotic surgery education: (1) Foundational Competence, which includes platform-specific training, ergonomics, teamwork, and emergency protocols; (2) Surgical Competence, focusing on systematic procedural training and stepwise surgical execution; and (3) Task-Based Micro-Competence, addressing fundamental skills like hemostasis, lymph node dissection, vascular control, bowel mobilization, and robotic suturing. The framework highlights the importance of platform-specific technical skills, team dynamics, and cognitive ergonomics to enhance surgical efficiency and patient safety. Additionally, it underscores the necessity for standardized training methodologies adaptable to diverse robotic systems. The study advocates for incorporating simulation-based learning, modular training, and emergency drills into robotic surgery education to bridge the gap between traditional and robotic-assisted techniques. As robotic surgery continues to evolve, the proposed structured training approach ensures surgeons and surgical teams are equipped with the skills required to navigate various platforms, optimize patient outcomes, and advance the field of robotic-assisted surgery.

Background: Long-term survival in penile cancer is dependent on the presence and extent of lymph node metastases. Historically, inguinal lymph node dissection (ILND) has been performed via an open approach (O-ILND). More recently, minimally invasive surgical alternatives (MIS-ILND) such as video-endoscopic and robot-assisted ILND have emerged. This review aims to compare the (1) perioperative outcomes, (2) complication rates, and (3) oncological efficacy between O-ILND and MIS-ILND. Methods: We conducted a PRISMA-compliant meta-analysis including studies comparing O-ILND versus MIS-ILND for penile cancer. Outcomes were pooled in random-effects meta-analyses. Results: Sixteen articles comprising 1054 patients were analysed. There was an observed trend towards longer operative time for the MIS-ILND approach (mean difference 28 min; 95% CI −2 to 58 min, p = 0.06), particularly with the robotic-assisted technique. Total LN yield (mean 12.3, mean difference 0.3, 95% CI −0.3 to 0.9, p = 0.13), and positive LN (RR 0.98, 95% CI 0.88–1.10, p = 0.75) were similar between groups. MIS-ILND significantly reduced complication rates for both minor (RR: 0.65, 95% CI 0.45–0.94, p = 0.02) and major complications (RR: 0.25, 95% CI 0.12–0.53, p = 0.002). Particularly, there was also lower wound infection rate with MIS-ILND (RR: 0.43, 95% CI 0.22–0.82, p = 0.02), corresponding to a shorter hospital stay of average 4 days (MD −4, 95% CI −6–−2, p = 0.05). Rates of skin/flap necrosis, lymphedema, lymphocele, and drainage time did not differ significantly. Local groin recurrence and overall survival did not differ between approaches. Conclusions: MIS-ILND is associated with fewer perioperative complications and shorter hospitalisation without compromising oncologic outcomes. These findings support its broader adoption, particularly in high-volume centres with appropriate surgical expertise.

Introduction: The Briganti 2019 nomogram stratifies risk of lymph node involvement (LNI) in prostate cancer, reducing unnecessary pelvic lymph node dissection (PLND) during radical prostatectomy (RP). However the applicability of the nomogram in diverse populations remains under-explored, with only one external validation study performed in an Asian population to date. We aim to evaluate the performance of the nomogram in a large tertiary Asian institution.Methods: A retrospective cohort study was conducted, with analysis of the cancer registry in our tertiary institution of all patients who underwent RP with PLND between 1988 and 2023. The Briganti 2019 nomogram score was retrospectively calculated for each patient, and post-operative data was analyzed to determine rates of LNI in order to determine the performance of the nomogram in our cohort.Results: 437 patients were included, with a median Briganti score of 11.2% (IQR 3.9–28.5%). The mean number of lymph nodes excised per patient was 15.1±12. 292 (66.8%) patients had a Briganti score greater than 7%, but only 8.6% were noted to harbor pN1 disease after RP. In our Asian cohort, the 2019 Briganti nomogram only had a moderate discriminatory ability with an area under the receiver operating characteristic curve (AUC) of 0.77. On multivariate analysis, independent predictors of LNI in our population included percentage of positive biopsy cores [Odds Ratio (OR) 1.02, 95%CI 1.01–1.04, p=0.01] and extraprostatic extension on MRI prostate (OR 3.00, 95%CI 1.20–7.56, p=0.02).Conclusion: The Briganti 2019 nomogram, while effective in many settings, only had a moderate ability to identify patients with pN1 disease in our Asian cohort. With potential limitations in its generalizability to multiple populations, a re-evaluation of its thresholds and further calibration to other populations might be required.

Background and Objectives: Radiation therapy (RT) plays a crucial role in managing prostate cancer, offering effective disease control and improving survival rates in both localized and recurrent cases. However, RT can lead to hemorrhagic cystitis, a significant late complication resulting in chronic morbidity and other health issues. This study aims to evaluate the real-world incidence of radiation-induced hemorrhagic cystitis requiring surgical intervention. Materials and Methods: This retrospective cohort study analyzed data from prostate cancer survivors treated for hematuria at our center between January 2014 and January 2024. Patients were included if cystoscopy identified radiation cystitis as the cause of hematuria. Descriptive statistics were used, and binomial logistic regression analyses with univariate and multivariate analysis were performed to identify risk factors for worse outcomes. Results: Fifty-two patients met the inclusion criteria. The estimated cumulative incidence at a median follow-up of 5.3 years was 4.5%. Among the participants, 21.2% required more than two transurethral bladder fulguration (TUBF) procedures, and 38.5% needed more than two hospital admissions for hematuria management. The median time to the first fulguration was 64 months. Blood transfusions were necessary in 53.8% of cases, and 38.5% required hyperbaric oxygen therapy. Ultimately, 5.8% of the patients underwent cystectomy. Univariate analysis identified ischemic heart disease (IHD) and antiplatelet therapy as significant risk factors (OR: 5.17 and 5.18, respectively), along with longer time to first fulguration (OR: 5.02). Multivariate analysis confirmed antiplatelet therapy (OR: 2.8, p = 0.05) and time to first TUBF (OR: 1.8, p = 0.02) as significant predictors of multiple procedures. Conclusions: Radiation cystitis remains a significant burden on prostate cancer survivors. Patients on antithrombotic agents, those with delayed initial presentations, and those who received radiation as salvage therapy are more likely to experience higher morbidity.