Robot-assisted partial nephrectomy: continued refinement of outcomes beyond the initial learning curve

Preparing for the Worst: Management and Predictive Factors of Open Conversion During Minimally Invasive Renal Tumor Surgery (UroCCR-135 Study)

Background and objective

Data regarding open conversion (OC) during minimally invasive surgery (MIS) for renal tumors are reported from big databases, without precise description of the reason and management of OC. The objective of this study was to describe the rate, reasons, and perioperative outcomes of OC in a cohort of patients who underwent MIS for renal tumor initially. The secondary objective was to find the factors associated with OC.

Methods

Between 2008 and 2022, of the 8566 patients included in the UroCCR project prospective database (NCT03293563), who underwent laparoscopic or robot-assisted minimally invasive partial (MIPN) or radical (MIRN) nephrectomy, 163 experienced OC. Each center was contacted to enlighten the context of OC: "emergency OC" implied an immediate life-threatening situation not reasonably manageable with MIS, otherwise "elective OC". To evaluate the predictive factors of OC, a 2:1 paired cohort on the UroCCR database was used.

Key findings and limitations

The incidence rate of OC was 1.9% for all cases of MIS, 2.9% for MIRN, and 1.4% for MIPN. OC procedures were mostly elective (82.2%). The main reason for OC was a failure to progress due to anatomical difficulties (42.9%). Five patients (3.1%) died within 90 d after surgery. Increased body mass index (BMI; odds ratio [OR]: 1.05, 95% confidence interval [CI]: 1.01-1.09, p = 0.009) and cT stage (OR: 2.22, 95% CI: 1.24-4.25, p = 0.008) were independent predictive factors of OC.

Conclusions and clinical implications

In MIS for renal tumors, OC was a rare event (1.9%), caused by various situations, leading to impaired perioperative outcomes. Emergency OC occurred once every 300 procedures. Increased BMI and cT stage were independent predictive factors of OC.

Patient summary

The incidence rate of open conversion (OC) in minimally invasive surgery for renal tumors is low. Only 20% of OC procedures occur in case of emergency, and others are caused by various situations. Increased body mass index and cT stage were independent predictive factors of OC.

Cumulative sum analysis (CUSUM) for evaluating learning curve (LC) of robotic-assisted laparoscopic partial nephrectomy (RALPN)

Robotic-assisted laparoscopic partial nephrectomy (RALPN) is becoming a standard treatment for localized renal tumors worldwide. Data on the learning curve (LC) of RALPN are still insufficient. In the present study, we have attempted to gain further insight in this area by evaluating the LC using cumulative summation analysis (CUSUM). A series of 127 robotic partial nephrectomies were performed by two surgeons at our center between January 2018 and December 2020. CUSUM analysis was used to evaluate LC for operative time (OT). The different phases of surgical experience were compared in terms of perioperative parameters and pathologic outcomes. In addition, multivariate linear regression analysis was used to confirm the results of the CUSUM analysis by adjusting the phases of surgical experience for the other confounding factors that may affect OT. The median age of patients was 62 years, mean BMI was 28, and mean tumor size was 32 mm. Tumor complexity was classified as low, intermediate, and high risk according to the PADUA score in 44%, 38%, and 18%, respectively. The mean OT was 205 min, and trifecta was achieved in 72.4%. According to the CUSUM diagram, the LC of OT was divided into three phases: initial learning phase (18 cases), plateau phase (20 cases), and mastery phase (subsequent cases). The mean OT was 242, 208, and 190 min in the first, second, and third phases, respectively (P < 0.001). Surgeon experience phases were significantly associated with OT in multivariate analysis considering other preoperative and operative parameters. Surgical outcome was comparable between the three phases in terms of complications and achievement of trifecta; hospital stay was shorter in the mastery phase than in the first 2 phases (4 days vs 5 days, P = 0.02). The LC for RALPN is divided into 3 performance phases with CUSUM. Mastery of surgical technique was achieved after performing 38 cases. The initial learning phase of RALPN has no negative impact on surgical and oncologic outcomes .

Impact of Surgical Experience Before Robot-assisted Partial Nephrectomy on Surgical Outcomes: A Multicenter Analysis of 2500 Patients

Background

Robot-assisted partial nephrectomy (RAPN) is a challenging procedure that is influenced by a multitude of factors.

Objective

To assess the impact of prior surgical experience on perioperative outcomes in RAPN.

Design setting and participants

In this retrospective multicenter study, results for 2548 RAPNs performed by 25 surgeons at eight robotic referral centers were analyzed. Perioperative data for all consecutive RAPNs from the start of each individual surgeon's experience were collected, as well as the number of prior open or laparoscopic kidney surgeries, pelvic surgeries (open, laparoscopic, robotic), and other robotic interventions.

Intervention

Transperitoneal or retroperitoneal RAPN.

Outcome measurements and statistical analysis

The impact of prior surgical experience on operative time, warm ischemia time (WIT), major complications, and margin, ischemia, complication (MIC) score (negative surgical margins, WIT ≤20 min, no major complications) was assessed via univariate and multivariable regression analyses accounting for age, gender, body mass index (BMI), American Society of Anesthesiologists score, PADUA score, and RAPN experience.

Results and limitations

BMI, PADUA score, and surgical experience in RAPN had a strong impact on perioperative outcomes. A plateau effect for the learning curve was not observed. Prior laparoscopic kidney surgery significantly reduced the operative time (p < 0.001) and WIT (p < 0.001) and improved the MIC rate (p = 0.022). A greater number of prior robotic pelvic interventions decreased WIT (p = 0.011) and the rate of major complications (p < 0.001) and increased the MIC rate (p = 0.011), while prior experience in open kidney surgery did not. One limitation is the short-term follow-up.

Conclusions

Mastering of RAPN is an ongoing learning process. However, prior experience in laparoscopic kidney and robot-assisted pelvic surgery seems to improve perioperative outcomes for surgeons when starting with RAPN, while experience in open surgery might not be crucial.

Patient summary

In this multicenter analysis, we found that a high degree of experience in keyhole kidney surgery and robot-assisted pelvic surgery helps surgeons in achieving good initial outcomes when starting robot-assisted kidney surgery.

Robotic-Assisted Partial Nephrectomy: Techniques to Improve Clinical Outcomes

PURPOSE OF REVIEW

To summarize current options available for robot-assisted partial nephrectomy RECENT FINDINGS: Partial nephrectomy (PN) is a standard treatment option for management of cT1 renal masses. It may be carried out by multiple approaches. Robot-assisted (RA) PN is one such option. The goal of treatment is both correct oncological (negative surgical margins) and functional (preservation of sufficient amount of renal parenchyma of the operated kidney) outcome. Appropriate outcomes depend on multiple factors. There are many, but among others tumor characteristics (size, location, i.e., tumor complexity), patient baseline renal function, patient comorbidities, and performance status etc. Based on all these, the surgeon adapts the intervention for each mass/patient by preoperative planning, absence/use/duration of warm or cold ischemia, perioperative imaging, resection technique adapted to tumor location and depth of invasion, use of hemostatics, type and degree of renal parenchymal closure and others details. Nephroprotective agents have not shown efficacy so far. It should not be forgotten that surgeon's experience plays a key role in the achievement of good results. Although multiple factors have a role in the RA partial nephrectomy, surgeon experience and adaptation of technique of intervention have the crucial role in the achievement of both functional and oncological results.

Folate-targeted intraoperative fluorescence, OTL38, in robotic-assisted laparoscopic partial nephrectomy

OBJECTIVE

To investigate the safety and efficacy of OTL38, a folate-targeted, intraoperative fluorescence agent, in patients undergoing robotic-assisted laparoscopic partial nephrectomy.

METHODS

Patients with proven or suspected localized renal cell carcinoma at a single academic institution were selected from 2016 to 2018. Patients received one dose of OTL38 at 0.025 mg/kg prior to robotic-assisted laparoscopic partial nephrectomy. The da Vinci Fluorescence Imaging Vision System was used to identify the tumor and inspect for residual disease after resection. Immunohistochemistry was performed to quantify folate receptor alpha in both the tumor and surrounding normal parenchyma. Patient follow-up was 1 month. Outcome data included descriptive statistics of the patient cohort and surgeon and pathologist surveys.

RESULTS

Ten cases were performed. Mean patient age was 62.9 years (range = 50-70). Mean tumor size was 2.45 cm. Pathologic tumor stages ranged from T1a-T3a. Histologic tumor types included clear cell, chromophobe, type 1 papillary renal cell carcinoma and oncocytoma. The tumors did not fluoresce, while the surrounding normal parenchyma did show fluorescence. No adverse reactions were seen. Staining for folate receptor alpha was localized to the proximal renal tubules. Average staining in normal surrounding renal parenchyma was significantly greater than staining observed in tumor tissue (0.2086 vs 0.0467; p = 0.002). The mean difference in staining between tumor tissue and surrounding normal renal parenchyma was 0.1619 (95% CI = 0.0796-0.2442).

CONCLUSIONS

Based on our initial experience, OTL38 shows potential as a safe, effective and easy to use tool to improve visualization and resection of renal tumors.

Trifecta achievement in patients undergoing partial nephrectomy: a systematic review and meta-analysis of predictive factors

PURPOSE

The predictors of trifecta achievement in partial nephrectomy (PN) were poorly inquired and remained a controversial area of discovery. To evaluate predictive factors of trifecta achievement in patients undergoing PN.

MATERIALS AND METHODS

A systematic literature search was performed to identify relevant articles. Only studies focusing on postoperative trifecta achievement and exploring its predictor with multivariable analyses were included. The trifecta achievement was defined as negative surgical margins, warm ischemia time <25 minutes, and no complications. Merged odds ratio (OR) and 95% confidence interval (CI) were used to evaluate the predictive effect.

RESULTS

Thirteen studies with 7066 patients meeting the inclusion criteria were included. The rate of trifecta achievement ranged from 43.3% to 78.6%. Merged results showed that preoperative eGFR (OR: 1.01, 95% CI: 1.00, 1.02, P=0.02), operative time (OR: 0.99, 95% CI: 0.99, 1.00, P=0.02), estimated blood loss (OR: 1.00, 95% CI: 1.00, 1.00, P <0.001), tumor size (OR: 0.70, 95% CI: 0.58, 0.84, P <0.001), medium (OR: 0.39, 95% CI: 0.18, 0.84, P=0.02) and high PADUA score (OR: 0.23, 95% CI: 0.08, 0.64, P=0.005) were independently associated with trifecta achievement. A publication bias was identified for tumor size. Sensitivity analysis confirmed the stability of result for tumor size.

CONCLUSIONS

Larger tumor size, medium and high PADUA score are associated with decreased probability of trifecta achievement. After verifying by further high-quality studies, these variables can be incorporated into tools to predict probability of trifecta achievement during clinical practice.

Application of IRIS Three-Dimensional Anatomical Models As Preoperative Surgical Planning Tools in the Management of Localized Renal Masses

Introduction: The use of volume-rendered images is gaining popularity in the surgical planning for complex procedures. IRIS™ is an interactive software that delivers three-dimensional (3D) virtual anatomical models. We aimed to evaluate the preoperative clinical utility of IRIS for patients with ≤T2 localized renal tumors who underwent either partial nephrectomy (PN) or radical nephrectomy (RN). Patients and Methods: Six urologists (four faculty and two trainees) reviewed CT scans of 40 cases over 2 study phases, using conventional two-dimensional (2D) CT alone (Phase-I), followed by the CT + IRIS 3D model (Phase-II). After each review, surgeons reported their decision on performing a PN or an RN and rated (Likert scale) their confidence in completing the procedure as well as how the imaging modality influenced specific procedural decisions. Modifications to the choice of procedure and confidence in decisions between both phases were compared for the same surgeon. Concordance between surgeons was also evaluated. Results: A total of 462 reviews were included in the analysis (231 in each phase). In 64% (95% CI: 58-70%) of reviews, surgeons reported that IRIS achieved a better spatial orientation, understanding of the anatomy, and offered additional information compared with 2D CT alone. IRIS impacted the planned procedure in 20% of the reviews (3.5% changed decision from PN to RN and 16.5% changed from RN to PN). In the remaining 80% of reviews, surgeons' confidence increased from 78% (95% CI: 72-84%) with 2D CT, to 87% (95% CI: 82-92%) with IRIS (p = 0.02); this confidence change was more pronounced in cases with a high RENAL score (p = 0.009). In 99% of the reviews, surgeons rated that the IRIS accurately represented the anatomical details of all kidney components. Conclusion: Application of IRIS 3D models could influence the surgical decision-making process and improve surgeons' confidence, especially for robot-assisted management of complex renal tumors.

Factors Associated With Receipt of Partial Nephrectomy or Minimally Invasive Surgery for Patients With Clinical T1a and T1b Renal Masses: Implications for Regionalization of Care

PURPOSE

To identify factors associated with receipt of partial nephrectomy (PN) and minimally invasive surgery (MIS) in patients with clinical T1 renal cell carcinoma (RCC) using the National Cancer Data Base (NCDB).

METHODS

We queried the NCDB from 2010 to 2014 identifying patients treated surgically for cT1a-bN0M0 RCC. Logistic regression was used to examine associations between socioeconomic, clinical, and treatment factors, and receipt of MIS or PN within the T1 patient population.

RESULTS

Our cohort included 69,694 patients (cT1a, n = 44,043; cT1b, n = 25,651). For cT1a tumors, 70% of patients received PN and 65% underwent MIS. For cT1b tumors, 32% of patients received PN and 62% underwent MIS. cT1a and cT1b patients with household income < $62,000, without private insurance, and treated outside academic centers were less likely to receive MIS or PN. cT1a patients traveling > 31 miles were more likely to undergo MIS. For both cT1a/b, the farther a patient traveled for treatment, the more likely a PN was performed.

CONCLUSION

Data showed an increase in utilization of MIS and PN from 2010 to 2014. However, patients in the lowest socioeconomic groups were less likely to travel and were more likely to receive more invasive treatments. On the basis of these findings, additional research is needed into how regionalization of RCC surgery affects treatment disparities.

Three Different Learning Curves Have an Independent Impact on Perioperative Outcomes After Robotic Partial Nephrectomy: A Comparative Analysis

Background

Robot-assisted partial nephrectomy (RAPN) has become widely accepted, but its different underlying types of learning curves have not been comparatively analyzed to date. This study aimed to determine and compare the impact that the learning curve of the department, the console surgeon, and the bedside assistant as well as patient-related factors has on the perioperative outcomes of RAPN.

Methods

The study retrospectively analyzed 500 consecutive transperitoneal RAPNs (2007–2018) performed in a tertiary referral center by 7 surgeons and 37 bedside assistants. Patient characteristics and surgical data were obtained. Experience (EXP) was defined as the current number of RAPNs performed by the department, the surgeon, and the assistant. As the primary outcome, the impact of EXP and patient-related factors on perioperative outcomes were analyzed and compared. As the secondary outcome, a cutoff between “experienced” and “inexperienced” was defined. Correlation and regression analysis, receiver operating characteristic curve analysis, Fisher’s exact test, and the Mann–Whitney U test were performed, with p values lower than 0.05 denoting significance.

Results

The EXP of the department, the surgeon, and the assistant each has a major influence on perioperative outcome in RAPN irrespective of patient-related factors. Perioperative outcomes improve significantly with EXP greater than 100 for the department, EXP greater than 35 for the surgeon, and EXP greater than 15 for the assistant.

Conclusions

The perioperative results of RAPN are influenced by three different types of learning curves including those for the surgical department, the console surgeon, and the assistant. The influence of the bedside assistant clearly has been underestimated to date because it has a significant impact on the perioperative outcomes of RAPN.

Electronic supplementary material

The online version of this article (10.1245/s10434-020-08856-1) contains supplementary material, which is available to authorized users.

Assessment of Advanced Perioperative Outcomes to Identify the True Learning Curve of Robotic-assisted Partial Nephrectomy

OBJECTIVES

To evaluate the learning curve of robotic-assisted partial nephrectomy as it pertains to operative time (OT) and advanced perioperative variables such as achievement of trifecta, postoperative complications, 30-day readmission rates (RR), warm ischemia time (WIT), and functional volume loss (FVL).

METHODS

We evaluated 418 consecutive robotic-assisted partial nephrectomy performed by a single surgeon between February 2008 and April 2019. Multivariable log-log regression models were used to evaluate the associations between case number and continuous outcomes (OT, WIT, and FVL). Multivariable logistic regression models were used to evaluate the association of case number with dichotomous outcomes (trifecta, postoperative complications, RR).

RESULTS

Among the 406 eligible patients included in the study, 252 (62.1%) were male, median age was 63 years (range, 22-84), and median body mass index was 29 kg/m² (interquartile range 26-33). Surgeon experience was associated with shorter OT (-2.5% per 50% increase in case number; 95% confidence interval; P <.001) and plateaus around 77 cases performed. There was slight improvement with trifecta (odds ratio [per 50% increase in cases] = 1.08; 95% confidence interval) and the plateau was also at 77 cases, however, this was not statistically significant (P = .086). We did not find statistically significant associations of surgeon experience with FVL (P = .77), postoperative complications (P = .74), WIT (P = .73), or 30-day RR (P = .33).

CONCLUSION

There does not appear to be a relationship between surgical experience and grade 3 or higher postoperative complications, 30-day RR, WIT, or FVL. Trifecta outcomes and maximum OT performance appear to be optimized at approximately 77 cases.

Retroperitoneal single-site robot-assisted partial nephrectomy using Lapsingle Vision advanced access platform: initial three case reports

Robot-assisted partial nephrectomy is currently the standard for treatment of small renal mass. Recently, robot-assisted single site surgery has been introduced. However, there have been few reports of retroperitoneal approaches. Herein, we report initial case series of retroperitoneal single-site robot-assisted partial nephrectomy using the da Vinci Xi surgical system using the Lapsingle Vision advanced access platform. Three patients have undergone retroperitoneal single-site robot-assisted partial nephrectomy due to incidental finding of renal mass. Operation duration, estimated blood loss, warm ischemia time, estimated glomerular filtration rate (eGFR) change, and complication were evaluated. Renal cell carcinoma of the two clear cell type and one chromophobe was diagnosed based on the pathological examination. Initial two cases were successfully completed with minimal bleeding and warm ischemic time within 25 minutes. The last 3rd case has been converted to multiport operation due to limited retroperitoneal space and difficulty in managing upper pole renal mass. Retroperitoneal single-site robot-assisted partial nephrectomy is a feasible treatment modality for treatment of posterior or lateral renal masses. Additional cases are needed to confirm the safety and efficacy of this technique.

Complications of robotic surgery in urological diseases: are we using standardized methodology to report complications?

PURPOSE OF REVIEW

The current data on complications reporting related to robot-assisted procedures (RAPs) in the urology literature are not comparable and do not use a validated classification. In this review, findings from various studies reporting positive and negative outcomes will be outlined.

RECENT FINDINGS

Robotic procedures have outcomes similar to open and laparoscopic techniques but generally cause fewer adverse events. However, the lack of standards for presenting surgical morbidity related to RAP leads to underreporting of surgical complications, makes comparisons of surgical outcomes difficult and prevents adequate knowledge about the outcomes of procedures.

SUMMARY

Although a reasonable number of positive outcomes of RAP have been reported in the literature, the extent of underreporting with this process is unknown. Further research and the development of a validated classification for reporting surgical complications will facilitate a better understanding of the actual outcomes.

Serving as a bedside surgeon before performing robotic radical prostatectomy improves surgical outcomes

INTRODUCTION

To evaluate the influence of previous experience as bedside assistants on patient selection, perioperative and pathological results in robot assisted laparoscopic radical prostatectomy.

MATERIALS AND METHODS

The first 50 cases of two robotic surgeons were reviewed retrospectively. Group 1 consisted of the first 50 cases of the surgeon with previous experience as a robotic bedside assistant between September 2016-July 2018, while group 2 included the first 50 cases of the surgeon with no bedside assistant experience between February 2009-December 2009. Groups were examined in terms of demographics, prostate volume, presence of median lobe, prostate specific antigen (PSA), preoperative Gleason score, positive core number, clinical stage, console surgery time, estimated blood loss, postoperative Gleason score, pathological stage, positive surgical margin rate, postoperative complications, length of hospital stay and biochemical recurrence rate.

RESULTS

Previous abdominal surgery and the presence of median lobe hypertrophy rates were higher in Group 1 than in Group 2 (20% vs. 4%, p=0.014; 24% vs. 6%, p=0.012; respectively). In addition, patients in Group 1 were in a higher clinical stage than those in Group 2 (cT2: 70% vs. 28%, p=0.001). Median console surgery time and median length of hospital stay was significantly shorter in Group 1 than in Group 2 (170 min vs. 240 min, p=0.001; 3 vs. 4, p=0.022; respectively). Clavien grade 3 complication rate was higher in Group 2 but was statistically insignificant.

CONCLUSION

Our findings might reflect that previous bedside assistant experience led to an increase in self-confidence and the ability to manage troubleshooting and made it more likely for surgeons to start with more difficult cases with more challenging patients. It is recommended that novice surgeons serve as bedside assistants before moving on to consoles.

Initial learning curve for robot-assisted partial nephrectomy performed by a single experienced robotic surgeon

INTRODUCTION

The objective of this study was to evaluate the initial learning curve for robot-assisted partial nephrectomy (RAPN) using the da Vinci Xi Surgical System (Intuitive Surgical, Sunnyvale, California).

METHODS

This study included the initial 65 consecutive patients with small renal tumors who had undergone RAPN at our institution. A single trained surgeon with extensive experience in robot-assisted radical prostatectomy, but not in laparoscopic partial nephrectomy, performed RAPN for all patients using the da Vinci Xi. The learning curve was analyzed by examining the perioperative outcomes among five groups each consisting of 13 consecutive patients.

RESULTS

In this series, the median tumor size and R.E.N.A.L. nephrometry score were 23 mm and 7, respectively, and the median console time and warm ischemia time (WIT) were 116 and 15 minutes, respectively. Fifty-eight patients (89.2%) achieved trifecta outcomes, meaning that the ischemic time was ≤25 minutes, there was a negative surgical margin, and no major postoperative complications occurred. Although there were no significant changes in R.E.N.A.L. nephrometry scores over time, increased surgeon experience was significantly associated with a shorter console time and WIT. Drawing logarithmic approximation curves enabled the achievement of a console time ≤150 minutes and WIT ≤20 minutes at the sixth and fourth procedures, respectively. Furthermore, multivariate analysis identified an independent correlation between surgeon experience with WIT, but not with console time.

CONCLUSION

These findings suggest that regardless of a surgeon's prior experience in laparoscopic partial nephrectomy, an experienced robotic surgeon can perform RAPN using the da Vinci Xi with acceptable perioperative outcomes after a small number of procedures.

Early Single-Center Experience with Robotic Partial Nephrectomy Using the da Vinci Xi: Comparative Assessment with Conventional Open Partial Nephrectomy

Background

The objective of this study was to evaluate our experience with robot-assisted partial nephrectomy (RAPN) in comparison with conventional open partial nephrectomy (OPN).

Patients and Methods

This study included 37 and 50 patients undergoing OPN and RAPN for small renal masses, respectively. A single surgeon performed RAPN for all 50 cases using the da Vinci Xi. Trifecta was defined as satisfying all of the following 3 criteria: ischemic time of ≤ 25 minutes, negative surgical margin and no major postoperative complications.

Results

After adjusting patient variables by 1:1 propensity-score matching, 37 patients were included in each group, and no significant differences in major clinicopathological characteristics were noted between these 2 groups. RAPN was significantly superior to OPN with respect to operative time, estimated blood loss and postoperative length of hospital stay. The rate of trifecta achievement was significantly higher in the RAPN group than in the OPN group (91.9 vs. 62.2%). Furthermore, the operative procedure and R.E.N.A.L. nephrometry score were found to be independently associated with trifecta outcome by multivariate analysis of the entire cohort.

Conclusions

Although this is our early experience with 50 initial cases, RAPN using the da Vinci Xi resulted in more favorable perioperative outcomes than OPN.

The safety of urologic robotic surgery depends on the skills of the surgeon

PURPOSE

To assess the available literature evidence that discusses the effect of surgical experience on patient outcomes in robotic setting. This information is used to help understand how we can develop a learning process that allows surgeons to maximally accommodate patient safety.

METHODS

A literature search of the MEDLINE/PubMed and Scopus database was performed. Original and review articles published in the English language were included after an interactive peer-review process of the panel.

RESULTS

Robotic surgical procedures require high level of experience to guarantee patient safety. This means that, for some procedures, the learning process might be longer than originally expected. In this context, structured training programs that assist surgeons to improve outcomes during their learning processes were extensively discussed. We identified few structured robotic curricula and demonstrated that for some procedures, curriculum trained surgeons can achieve outcomes rates during their initial learning phases that are at least comparable to those of experienced surgeons from high-volume centres. Finally, the importance of non-technical skills on patient safety and of their inclusion in robotic training programs was also assessed.

CONCLUSION

To guarantee safe robotic surgery and to optimize patient outcomes during the learning process, standardized and validated training programs are instrumental. To date, only few structured validated curricula exist for standardized training and further efforts are needed in this direction.

Assessment of surgical skills by using surgical navigation in robot-assisted partial nephrectomy

PURPOSE

To assess surgical skills in robot-assisted partial nephrectomy (RAPN) with and without surgical navigation (SN).

METHODS

We employed an SN system that synchronizes the real-time endoscopic image with a virtual reality three-dimensional (3D) model for RAPN and evaluated the skills of two expert surgeons with regard to the identification and dissection of the renal artery (non-SN group, n = 21 [first surgeon n = 9, second surgeon n = 12]; SN group, n = 32 [first surgeon n = 11, second surgeon n = 21]). We converted all movements of the robotic forceps during RAPN into a dedicated vocabulary. Using RAPN videos, we classified all movements of the robotic forceps into direct action (defined as movements of the robotic forceps that directly affect tissues) and connected motion (defined as movements that link actions). In addition, we analyzed the frequency, duration, and occupancy rate of the connected motion.

RESULTS

In the SN group, the R.E.N.A.L nephrometry score was lower (7 vs. 6, P = 0.019) and the time to identify and dissect the renal artery (16 vs. 9 min, P = 0.008) was significantly shorter. The connected motions of inefficient "insert," "pull," and "rotate" motions were significantly improved by SN. SN significantly improved the frequency, duration, and occupancy rate of connected motions of the right hand of the first surgeon and of both hands of the second surgeon. The improvements in connected motions were positively associated with SN for both surgeons.

CONCLUSION

This is the first study to investigate SN for nephron-sparing surgery. SN with 3D models might help improve the connected motions of expert surgeons to ensure efficient RAPN.

The ERUS Curriculum for Robot-assisted Partial Nephrectomy: Structure Definition and Pilot Clinical Validation

BACKGROUND

No validated training program for robot-assisted partial nephrectomy (RAPN) exists.

OBJECTIVE

To define the structure and provide a pilot clinical validation of a curriculum for robot-assisted partial nephrectomy (RAPN).

DESIGN, SETTING, AND PARTICIPANTS

A modified Delphi consensus methodology involving 27 experts defined curriculum structure. One trainee completed the curriculum under the mentorship of an expert. A total of 40 patients treated with curriculum RAPN (cRAPN) were compared with 160 patients treated with standard of care (sRAPN).

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

To define curriculum structure, consensus was defined as ≥90% expert agreement. To investigate curriculum safety, perioperative morbidity, renal function, and pathologic outcomes were evaluated. To investigate curriculum efficacy, RAPN steps and modules attempted and completed by the trainee were evaluated. Propensity score matching identified comparable cRAPN and sRAPN cases. Mann-Whitney U test, chi-square test, and linear regression were used to investigate the impact of the curriculum on patient's outcome and the impact of trainee's experience on surgical independence.

RESULTS AND LIMITATIONS

Consensus-based key statements defined curriculum structure. No difference was recorded between cRAPN and sRAPN with respect to intraoperative or overall and grade-specific postoperative complications, blood loss, ischemia time, postoperative estimated glomerular filtration rate, and positive surgical margins (all p>0.05). Conversely, operative time was longer after cRAPN (p<0.0001). The trainee completed all phases of the curriculum and the trainee's experience was associated with more steps attempted/completed and increasing complexity of module attempted/completed (all p<0.0001). The limitations of the study are the enrolment of a single trainee at a single institution and the small sample size. Accordingly, the large confidence intervals observed cannot exclude inferior outcomes in case of cRAPN and further study is required to confirm safety.

CONCLUSIONS

The European Association of Urology (EAU) Robotic Urology Section (ERUS) curriculum for RAPN can protect patients from suboptimal outcome during the learning curve of the surgeon and can aid surgeons willing to start an RAPN program.

PATIENT SUMMARY

Patients should be aware that structured training programs can reduce the risk of suboptimal outcome due to the learning curve of the surgeon.

Impact of learning curve on the perioperative outcomes following robot-assisted partial nephrectomy for renal tumors

INTRODUCTION

Robot-assisted partial nephrectomy (RAPN) is an established, minimally invasive technique to treat patients with renal masses. The aim of this study was to assess the learning curve (LC) of RAPN, evaluate its impact on perioperative outcomes following RAPN and to study the role of surgeon experience in achieving "trifecta" outcomes following RAPN.

METHODS

We prospectively analyzed the clinical and pathological outcomes of 108 consecutive patients who underwent RAPN for renal tumors from January 2012 to December 2016 by a laparoscopy trained surgeon with no prior robotic experience. We used warm ischemia time (WIT) <20 min, operative time <120 min, and blood loss <100 ml as endpoints for plotting the LCs. Trifecta was analyzed in relation to our LC.

RESULTS

Surgeon experience was found to correlate with WIT, operative time, and blood loss. Overall 18.5% of patients developed complications. Complication rate reduced with increasing surgeon experience. LC was 44 cases for WIT ≤20 min, 44 cases for operative time <120 min, and 54 cases for blood loss <100 ml. Trifecta outcome was achieved in 67.6% patients overall and was found to correlate with increasing surgeon experience. Improvement in trifecta outcomes continued to occur beyond the LC.

CONCLUSIONS

RAPN is a viable option for nephron-sparing surgery in patients with renal carcinoma. For a surgeon trained in laparoscopy, acceptable perioperative outcomes following RAPN can be achieved after an LC of about 44 cases. Increasing surgeon experience was associated with improved "trifecta" achievement following RAPN.