Trifecta Outcomes to Assess Learning Curve of Robotic Partial Nephrectomy

Abstract

Background and Objectives:The learning curve for achieving desirable perioperative outcomes in robot-assisted partial nephrectomy (RAPN) has not been well studied. Information is available regarding “trifecta” outcomes of no complications, no positive margins, warm ischemia time (WIT) of ≤25 minutes, and a ≤15% decrease in postoperative glomerular filtration rate (GFR). This study was conducted to assess the impact of the learning curve on surgical outcomes in patients undergoing RAPN.Methods:We reviewed 131 consecutive patients who underwent RAPN by a single, fellowship-trained surgeon from October 2007 through June 2015. Patients were divided into 4 subgroups, and mean perioperative values were compared. The learning curve was evaluated as the time it took the surgeon to attain a trifecta outcome.Results:Means for the RENAL Nephrometry Score, procedure length, WIT, and estimated blood loss (EBL) were 5.3 ± 1.2, 172.1 ± 43.5 minutes, 22.7 ± 7.0 minutes, and 267.2 ± 341.8 mL, respectively. Significance was noted for differences in WIT (P = .50), postoperative creatinine (P = .006), postoperative estimated (e)GFR (P = .40), and percentage change in creatinine (P = .023). The learning curve for achieving positive outcomes was noted in >61–90 cases after 66–80 months of performing minimally invasive partial nephrectomy surgeries at a rate of 20 cases per year.Conclusion:RAPN is a safe, feasible procedure with slightly better surgical outcomes than laparoscopic partial nephrectomy (LPN). In the hands of an experienced surgeon, the learning curve for achieving trifecta outcomes can involve a significant number of cases over several years.

Minimal Invasive Treatments for Renal Cell Carcinoma

“…RAPN has emerged as an alternative to LPN for removal of renal tumors for shortening the learning curve associated with laparoscopy. The benefits are a greater range of motion, greater manual dexterity and flexibility, optically magnified imaging, enhanced visualization, precision of control and tremor reduction resulting resulting in reduced total operation time and less amount of experience required by the surgeon [43][44][45][46]. In their study Omidele et al showed that RAPN is a safe, effective treatment modality for small renal masses, the outcomes are better than LPN and is a technically easier procedure to master.…”

“…In their study Omidele et al showed that RAPN is a safe, effective treatment modality for small renal masses, the outcomes are better than LPN and is a technically easier procedure to master. This goal can be reached after >61-90 cases at a rate of 20 cases per year [43]. ''Trifecta" is a statement used in radical prostatectomy and now Hung et al [47,48] introduced the outcomes of partial nephrectomy as; providing negative surgical margins, minimal renal function decrease, and absence of complications in the same patient.…”

“…As renal injury is directly proportional with warm ischemia time (WIT), after the first introducing; some authors defined as no complications, negative surgical margins, and WIT ≤25 minutes [48][49][50] [48,50]. Their conclusion is RAPN for T1b renal masses may be safely performed in experienced hands.Although the benefits of the LPN, it is a more challenging procedure for the surgeon because of its reconstructive nature and the increased risk of intraoperative bleeding and postoperative complications [17,43]. Studies have shown LPN to be a difficult procedure with a lengthy learning curve and requires extensive repetition achieve the type of perioperative outcomes [43].…”

“…Their conclusion is RAPN for T1b renal masses may be safely performed in experienced hands.Although the benefits of the LPN, it is a more challenging procedure for the surgeon because of its reconstructive nature and the increased risk of intraoperative bleeding and postoperative complications [17,43]. Studies have shown LPN to be a difficult procedure with a lengthy learning curve and requires extensive repetition achieve the type of perioperative outcomes [43]. RAPN has emerged as an alternative to LPN for removal of renal tumors for shortening the learning curve associated with laparoscopy.…”

Robot-assisted partial nephrectomy: How to minimise renal ischaemia

“…The increased number of RAPNs performed by a surgeon correlates with a lower WIT and hence improvement in the patient outcome. Studies have shown the learning curve to achieve an ideal WIT of <25 min ranges from 44 to 60 cases [38] , [39] .…”