Learning Curve for Robotic-Assisted Laparoscopic Retroperitoneal Lymph Node Dissection

Abstract

Introduction: Robotic retroperitoneal lymph node dissection (R-RPLND) is a challenging procedure. We hypothesized that surgical times and operative complications would decrease as surgeons became more facile with R-RPLND. Materials and Methods: We retrospectively reviewed 121 consecutive R-RPLNDs performed at Naval Medical Center San Diego and Mayo Clinic Arizona by 4 fellowship trained robotic surgeons between 2008 and 2018. Linear regression was used to analyze independent predictors of setup time, operative time, and lymph node counts. Logistic regression was used to analyze open conversions, overall complications, and high-grade complications. Variables included as independent predictors were: sequential case number, surgeon, clinical stage, chemotherapy status, RPLND template, and body mass index. Univariate and multivariate analyses were conducted. Statistical significance was established at a = 0.05. Results: There was no change in setup time with case number ( p = 0.317), but differences were noted between surgeons. Operative times decreased with increasing case number ( p < 0.001) but were negatively affected by clinical stage III testis cancer ( p = 0.029) and history of chemotherapy exposure ( p = 0.050). Surgical times are predicted to decrease by 1 hour after 44 cases. Lymph node counts were dependent only on the surgeon. No factors were predictive of open conversions. Fewer overall complications occurred as experience was gained ( p = 0.001), but high-grade complications could not be predicted. Conclusions: Consistent with the learning curves shown for other technologically advanced surgical techniques, experience appears to improve surgical times and lower complication rates for R-RPLND.

Advances in diagnosis and treatment of testicular cancer

“…Studies performing laparoscopic and robotic assisted surgeries report satisfactory therapeutic results and low to no morbidity. [158][159][160][161][162] However, a study assessing patients referred to Indiana University for recurrence reported aberrant recurrence patterns after minimally invasive surgeries. All five patients had recurrences in abnormal locations compared with past routine experience.…”

“…In recent years there have been initiatives to decrease the morbidity of surgery with minimally invasive surgery. Studies performing laparoscopic and robotic assisted surgeries report satisfactory therapeutic results and low to no morbidity 158159160161162. However, a study assessing patients referred to Indiana University for recurrence reported aberrant recurrence patterns after minimally invasive surgeries.…”

Comparison of Minimally Invasive Versus Abdominal Radical Hysterectomy for Early-Stage Cervical Cancer: An Updated Meta-Analysis

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Robotic-assisted retroperitoneal lymph node dissection for testicular cancer

“…R-RPLND is technically challenging with a significant learning curve, even when performed at high-volume centers. This is demonstrated by continuously decreasing operative times and improved outcomes across 121 cases [40]. Thus, surgical experience and operative technique may contribute to variation in peri-operative outcomes across studies.…”