Learning curve of laparoscopic nephrectomy: a prospective pilot study

Three-Dimensional Laparoscopic Nephrectomy for Benign Nonfunctioning Kidneys: A Single-Center Initial Experience

BACKGROUND

There are several types of benign renal diseases, such as urological stones, ureteropelvic junction obstruction, renal vascular disease, and inflammation, which are responsible for nonfunctioning kidneys. Laparoscopic nephrectomy (LN) is the gold standard for treating nonfunctioning kidneys with complications. This study presents the results of our initial experiences with 3D laparoscopic nephrectomy (3D-LN) for benign, nonfunctioning kidneys.

METHODS

From July 2021 to July 2023, 40 consecutive patients who underwent 3D transperitoneal laparoscopic nephrectomy were retrospectively evaluated at the Department of Urology and Department of General Surgery, Hue Central Hospital, Hue, Vietnam. Patient demographics, intraoperative and early postoperative results, postoperative recovery, complications, and three-month follow-up results were recorded.

RESULTS

The mean age was 58.35 ± 14.9 years. There were 13 (32.5%) male and 27 (67.5%) female patients. Flank pain was the main reason for hospitalization in 33 cases (82.5%); the common cause of a nonfunctioning kidney was urological stones (62.5%). Twenty-three out of 40 patients underwent a left nephrectomy. The average operative time was 92.57 ± 28.69 minutes. A statistically significant difference in surgery time was found between the group with no adhesion and the group with mild adhesion, as well as between the first 19 patients and the last 18 patients (p <0.05). The mean blood loss was 51.62 ± 24.35 ml. Three cases were converted to open surgery due to severe adhesions. The postoperative complications rate was 8.1%. The average length of the postoperative hospital stay was 7.89 ± 3.59 days.

CONCLUSIONS

Three-dimensional laparoscopic nephrectomy is a safe and effective method that increases depth perception and spatial orientation for surgeons and can compensate for the remaining shortcomings of traditional 2D systems.

Surgical outcome predictor analysis following hand-assisted or pure laparoscopic transperitoneal nephroureterectomy using the Taiwan upper urinary tract urothelial carcinoma database

Purpose

Taiwan has a high incidence of upper tract urothelial carcinoma (UTUC). This study aimed to compare the surgical outcomes following transperitoneal hand-assisted laparoscopic nephroureterectomy (TP-HALNU) and transperitoneal pure laparoscopic nephroureterectomy (TP-LNU) from the Taiwan nationwide UTUC collaboration database using different parameters, including surgical volumes.

Materials and methods

The nationwide UTUC collaboration database includes 14 hospitals in Taiwan from the Taiwan Cancer Registry. We retrospectively reviewed the records of 622 patients who underwent laparoscopic nephroureterectomy between July 1988 and September 2020. In total, 322 patients who received TP-LNU or TP-HALNU were included in the final analysis. Clinical and pathological data and oncological outcomes were compared.

Results

Of the 322 patients, 181 and 141 received TP-LNU and TP-HALNU, respectively. There were no differences in clinical and histopathological data between the two groups. No differences were observed in perioperative and postoperative complications. There were no significant differences in oncological outcomes between the two surgical approaches. In the multivariate analysis, the cohort showed that age ≥70 years, positive pathological lymph node metastasis, tumors located in the upper ureter, and male sex were predictive factors associated with an increased risk of adverse oncological outcomes. A surgical volume of ≥20 cases showed a trend toward favorable outcomes on cancer-specific survival [hazard ratio (HR) 0.154, p = 0.052] and marginal benefit for overall survival (HR 0.326, p = 0.019) in the multivariate analysis.

Conclusion

Although different approaches to transperitoneal laparoscopic nephroureterectomy showed no significant differences in surgical outcomes, age, sex, lymph node metastasis, and tumor in the upper ureter in the following period were predictive factors for oncological outcomes. Higher surgical volume did not impact disease-free survival and bladder recurrence-free survival but was associated with improved overall survival and cancer-specific survival. Exploration of unknown influencing factors is warranted.

Defining operative experience targets in surgical training: A systematic review

BACKGROUND

The surgical learning curve is an observable and measurable phenomenon. Operative experience targets are well established as a proxy measure for operative competence in surgical training across jurisdictions. The aim of this study was to critique the available evidence regarding the relationship between operative experience in surgical training and trainee competence.

METHODS

A systematic review of the PubMed, Embase, Web of Science, and Cochrane library databases was conducted in accordance with the Preferred Items for Systematic Reviews and Meta-Analyses guidelines. Articles were sought that defined the relationship between procedural volume in surgical training and trainee competence, proficiency, or mastery. The educational impact of included studies was evaluated using a modified Kirkpatrick model.

RESULTS

Of 3,672 records identified on database searching, 30 papers were ultimately included. Fourteen studies defined operative experience thresholds using operative time as a surrogate measure of competence, whereas another 8 used trainer assessments of operative performance (Kirkpatrick level 3). A further 5 studies were able to determine the relationship between trainee case volumes and subsequent patient outcomes (Kirkpatrick level 4b).

CONCLUSION

Many studies have recorded competent trainee performance in key index procedures after reaching experience threshold numbers in excess of currently mandated targets across jurisdictions. The evidence relating current operative experience targets to patient outcomes across a range of surgical subspecialties of surgical subspecialties is lacking. This review supports a move toward criterion-based referencing of operative performance targets in surgical training.

Laparoscopic versus open nephrectomy in resource-constrained developing world hospitals: a retrospective analysis

Background

Laparoscopic nephrectomy is the standard of care for nephrectomy in most developed countries. Its adoption in our setting has been limited due to lack of equipment and expertise. This paper sets out to show that laparoscopic nephrectomy is technically feasible in the state sector in South Africa.

Methods

A retrospective chart review was performed of all patients having undergone nephrectomy over a five-year period at two state hospitals in KwaZulu-Natal Province, South Africa. Demographic information, pre-operative imaging findings, operative information and post-operative outcomes were analysed.

Results

Nephrectomy was performed in 196 patients. Open nephrectomy (ON) was the intended surgical approach in 73% (n = 143) and laparoscopic nephrectomy (LN) in 27% (n = 53). The conversion rate from LN to ON was 11% (n = 6). For malignancies, there was no difference in surgical resection margin status across the ON, LN and conversion groups; however, tumour size was larger in the conversion group compared to the LN group. Estimated blood loss and transfusion rates were lower in the LN group. The average length of hospital stay was shorter in the LN group (5 vs 10 days). High dependency unit (HDU) admission rate was lower in the LN group (12.1%) compared to the ON group (50%) and the conversion group (40%). No difference in high-grade complications was noted between the ON and LN groups, and more patients in the LN group (82.5%) had no complications compared to the open group (9.9%).

Conclusion

LN is non-inferior to ON in terms of operative time, oncology outcomes and high-grade complications. LN is superior in terms of blood loss, transfusion rate, length of hospital stay and overall complication rate. LN appears to show technical feasibility in the state sector and highlights the need for laparoscopic training.