Transumbilical laparoendoscopic single-site surgery: more than 1-year experience in radical nephrectomy and its learning curve study

Oncologic and Functional Outcomes of Laparoendoscopic Single-Site Radical Nephrectomy for Localized Kidney Cancer: A Single Surgeon's Series with a Minimum of 3-Year Follow-Up

OBJECTIVE

To evaluate intermediate-term oncologic and renal functional outcome of laparoendoscopic single-site radical nephrectomy (LESS-RN) in the treatment of localized kidney cancer.

METHODS

We performed a chart review of patients who underwent LESS-RN between 2009 and 2011 at our institution. Patients with a minimum of 3 years of follow-up were included in this study. The demographic data and main perioperative outcome variables were analyzed. Estimated glomerular filtration rate was calculated using the Modification of Diet Renal Disease equation. Upstaging of chronic kidney disease (CKD) was calculated. The Kaplan-Meier method was used to calculate overall survival (OS), cancer-specific survival (CSS), and cancer-free survival (CFS). Multivariate logistic regression was performed to show predicting factors for an undesirable outcome arbitrarily defined as any one or more of the following events: surgical conversion, complication of Clavien grade >2, new onset of CKD stages ≥3 at the latest follow-up, or cancer recurrence or metastasis.

RESULTS

A total of 51 patients were included with a median follow-up of 41 (interquartile range: 38-45) months. The OS, CSS, and CFS rates at 3 years were 100%, 100%, and 98%, respectively. There was a 74.5% (38/51) upstaging of CKD at the latest follow-up, with 22 patients (43.1%) who developed a new onset of CKD stages ≥3. Multivariate analysis showed that patient age, body mass index, Charlson comorbidity index, early surgeon experience, and follow-up duration (all p < 0.05) have increased the odds of an undesirable outcome.

CONCLUSIONS

For localized kidney cancer, LESS-RN is effective in oncologic control at an intermediate follow-up interval but, similar to other kinds of RN technique, it is associated with worsened renal functional outcomes.

Have we learned from lessons of the past? A systematic review of training for single incision laparoscopic surgery

INTRODUCTION

Single incision laparoscopic surgery (SILS) represents the next step in laparoscopic surgery in further reducing the invasiveness of surgical procedures with cosmetic advantages. Recalling the increased rates of major complications at the advent of laparoscopic cholecystectomy 20 years ago, however, it is clear that appropriate training is required before adopting a new technique. This study aims to review the current evidence for training and skills acquisition for SILS.

METHODS

A comprehensive database search of PubMED, MEDLINE, EMBASE and Google Scholar was carried out. Studies considered for inclusion were those addressing SILS learning curves, skills acquisition, or training.

RESULTS

21 studies were included in the final analysis. Ten clinical case series with analysis of SILS learning curve demonstrated a significant learning curve for conventional multiport laparoscopic (LAP)-trained surgeons over the course of initial SILS cases, with several studies reporting increased risk of conversion and complication rates. Five laboratory-based studies demonstrated differences in SILS skills acquisition compared with LAP. Six studies describing SILS-specific training curricula were analysed, but none included a robust validation of the curriculum.

CONCLUSIONS

Clinical case series and laboratory-based skills acquisition studies demonstrate the unique requirements of SILS, with skill sets and ergonomic demands which cannot be directly adapted from existing LAP experience. Some studies have already reported higher complication rates in initial SILS cases. To avoid repeating the mistakes of the past, the implementation of an evidence- and competency-based SILS curriculum is necessary to ensure appropriate training of future SILS surgeons.