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

The IDEAL framework for surgical robotics: development, comparative evaluation and long-term monitoring

The next generation of surgical robotics is poised to disrupt healthcare systems worldwide, requiring new frameworks for evaluation. However, evaluation during a surgical robot's development is challenging due to their complex evolving nature, potential for wider system disruption and integration with complementary technologies like artificial intelligence. Comparative clinical studies require attention to intervention context, learning curves and standardized outcomes. Long-term monitoring needs to transition toward collaborative, transparent and inclusive consortiums for real-world data collection. Here, the Idea, Development, Exploration, Assessment and Long-term monitoring (IDEAL) Robotics Colloquium proposes recommendations for evaluation during development, comparative study and clinical monitoring of surgical robots-providing practical recommendations for developers, clinicians, patients and healthcare systems. Multiple perspectives are considered, including economics, surgical training, human factors, ethics, patient perspectives and sustainability. Further work is needed on standardized metrics, health economic assessment models and global applicability of recommendations.

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 .

Outcomes of Localized Renal Cell Carcinoma Across Different Races

Introduction: Epidemiological outcomes of renal cell carcinoma (RCC) remain sparse. This study aims to compare preoperative characteristics, surgical outcomes, and oncological outcomes of RCC patients at a urology unit in Singapore.Methods: A retrospective cohort analysis of 137 RCC patients in the National University Hospital of Singapore who had undergone partial nephrectomy between 2009 and 2020 was conducted. χ2 tests (Chi-Square Test, Fisher's Exact Test) and one-way analysis of variance (ANOVA) were used for comparing categorical and continuous variables respectively. Kaplan-Meier estimates were used for survival analysis.Results: In total, 137 patients were identified (Chinese [n=82], Malay [n=19], Indian [n=15], Others [n=21]). Indian patients were diagnosed at an earlier age (52.13±10.52 years, P=0.018). A larger percentage of Malay patients (78.9%, P<0.001) were operated on before 2016, prior to the center's adoption of the robotic surgical technique. More Malay and Indian patients underwent laparoscopic surgery (36.8% and 46.7%, P=0.008), experiencing higher rates of intra-operative conversions compared to the Chinese and other ethnicities (5.3% and 13.3% vs. 0%, P=0.011). They also had longer post-operative stays compared to Chinese (7.42±6.46 days; 7.40±7.69 days vs. 4.88±2.87 days, P=0.036). Malays were much less likely to undergo robotic partial nephrectomy compared to Chinese patients (OR=0.295, 95% CI=0.102-0.856) and had the highest rate of metastatic recurrence (10.5%, P=0.023).

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.

Factors influencing warm ischemia time in robot-assisted partial nephrectomy change depending on the surgeon's experience

INTRODUCTION

Warm ischemia time (WIT) is a primary concern for robot-assisted laparoscopic partial nephrectomy (RALPN) patients because longer WIT is significantly associated with postoperative deteriorating kidney function. Tumor complexity, determined by the RENAL nephrometry score (RENAL score), can help predict surgical outcomes, but it is unclear what RENAL score and clinical factors affect WIT. This study explored the clinical factors predicting long WIT in experienced surgeon to RALPN.

MATERIALS AND METHODS

In our institute, 174 RALPNs were performed between November 2013 and February 2021, of which 114 were performed by a single surgeon and included in this study. Clinical staging and the total RENAL score were determined based on preoperative CT scans. The cases were divided into three groups based on experience: period 1: 1-38, period 2: 39-76, and period 3: 77-114. The clinical factors associated with longer WIT were analyzed per period.

RESULTS

The overall median tumor diameter was 32 mm, and one patient had a positive surgical margin, but there were no cancer-related deaths. In total, there were 18 complications (15.8%). Periods 2 and 3 had larger tumor diameters (p < 0.01) and worse preoperative kidney function (p = 0.029) than period 1. A RENAL L-component score of 3 was associated with longer WIT in period 3 (odds ratio: 3.900; 95% confidence interval: 1.004-15.276; p = 0.044), but the tumor diameter and the total RENAL score were not.

CONCLUSIONS

A large tumor in the central lesion indicated by the RENAL L-component score was associated with increased WIT in RALPN.

Perioperative outcomes following robot-assisted partial nephrectomy for renal cell carcinoma according to surgeon generation

Objective

The experience of performing robot-assisted partial nephrectomy (RAPN) is associated with better surgical outcomes. However, surgeon’s generation may impact surgical outcomes. We evaluated the perioperative outcomes of RAPN between first- and second-generation surgeons according to the surgeon’s experience.

Methods

This study included 529 patients who underwent RAPN for renal cell carcinoma from January 2013 to November 2018. Four specific surgeons performed the surgery. According to the surgeon’s generation, the patients were divided into two groups: first-generation and second-generation. To reflect the learning curve of RAPN, the surgical outcomes of each case (1–50, 51–100, 101–150) were evaluated between these groups.

Results

Between 1 to 50 cases and 101–150 cases, no significant differences in patient characteristics were observed between the two generations. Between 51–100 cases, age at surgery was significantly younger in the first-generation than in the second-generation group (58 years vs. 64 years, p = 0.04). The second-generation group had a shorter operation time in cases 1–50 (169 min vs. 188 min, p = 0.0001), 51–100 (145 min vs. 169 min, p = 0.008), and 101–150 (142 min vs. 165 min, p = 0.009), than the first-generation group. Although shorter WIT and higher trifecta achievement were observed in the second-generation group than in the first-generation group between 1–50 cases, the difference was not noted between 51–100 cases and 101–150 cases.

Conclusion

Patients operated by second-generation surgeons had better surgical outcomes than first-generation surgeons, especially during the early experience period, which might result from their assistance experience, sophisticated surgical procedures refined by the first-generation, and the first-generation surgeon’s introduction.

[Robot-assisted surgery as an elective-fascinating lesson(s)?]

Hintergrund

Auch wenn sich roboterassistiertes Operieren zu einem verbreiteten Standardverfahren in einigen chirurgischen Fächern entwickelt hat, ist es im Lehrplan heutiger Medizinstudierender unterrepräsentiert.

Fragestellung

Wir berichten vom deutschlandweit ersten Wahlfach „Robotische Chirurgie“ für Studierende an einer urologischen Universitätsklinik.

Material und Methoden

In einer Kleingruppe mit zehn Studierenden wurden in sechs Treffen à 2 h theoretische Grundlagen und praktische Fertigkeiten in der robotischen Chirurgie vermittelt, inklusive einer Hospitation während einer urologischen roboterassistierten Operation. Der Zuwachs an Wissen (10 MCQ-Fragen) und Fähigkeiten (Übungen Camera 0, Clutch, Sea Spikes 1) an einem robotischen Simulationssystem wurde quantifiziert und die studentische Einschätzung evaluiert.

Ergebnisse

Bei den 10 Teilnehmenden war ein signifikanter Wissenszuwachs messbar, am Ende wurden in derselben theoretischen Prüfung im Median 3,5 mehr korrekte Antworten gegeben (p = 0,011). In zwei von drei praktischen Übungen stieg die Gesamtpunktzahl signifikant an (Camera 0 und Sea Spikes 1, für beide p < 0,05), in der Übung „Clutch“ verbesserte sich nur die Bewegungsökonomie (p = 0,028). Das Modul wurde (sehr) gut bewertet und die Teilnehmenden konnten sich am Ende deutlich stärker vorstellen, später Urologe/in zu werden (p = 0,007).

Schlussfolgerungen

Bei einem Bedarf von studentischer Seite, mehr über roboterassistierte Operationen zu lernen, erscheint ein Wahlfach als geeignetes Format, um theoretische Grundlagen und praktische Fertigkeiten in der robotischen (urologischen) Chirurgie zu vermitteln. Zusätzlich hat es das Potenzial, auf das Fachgebiet Urologie aufmerksam zu machen und könnte potenziell neue Kolleginnen und Kollegen gewinnen.

Zusatzmaterial online

Die Online-Version dieses Beitrags (10.1007/s00120-021-01756-6) enthält als zusätzliches Material das in diesem Beitrag durchgeführte Eingangstestat zur Prüfung des Vorwissens der Studierenden in einer theoretischen Prüfung (10 Multiple-choice-Fragen).

[Robot-assisted surgery for renal cell carcinoma - today a standard?]

Twenty years have passed since the first reports on robot-assisted kidney tumor surgery in 2001. However, robotic surgery has not spread to all German urologic departments yet. Hence, one has to question whether robot-assisted kidney tumor surgery can be considered a standard today. Until now, no prospective randomized controlled trials have compared robot-assisted radical nephrectomy with the open or laparoscopic approach. Regardless, laparoscopy and robotics both have proven better perioperative and comparable oncological outcomes than with open nephrectomy. In direct comparison, robot-assisted nephrectomy has no additional benefits over the laparoscopic approach and is less cost-effective. However, reports on robot-assisted level III or IV vena cava tumor thrombectomies illustrate that robotic surgery can be superior to the laparoscopic approach in highly complex interventions. Likewise, no prospective randomized controlled trials have analyzed robot-assisted partial nephrectomy yet. When conducted by experienced surgeons, robotic and laparoscopic partial nephrectomies can also have lower morbidity compared to the open approach. No consensus has been reached when directly comparing robotic and laparoscopic partial nephrectomy. However, evidence is increasing that robot-assisted partial nephrectomy can offer additional benefits, especially for the treatment of highly complex endophytic renal tumors. Thereof, head-to-head comparisons are often impacted by patient- and tumor-related factors, as well as the learning curve of the surgeon, bed-side assistant and the annual caseload of the department. Hence, one has to conclude that robot-assisted kidney tumor surgery has evolved into a standard procedure with good results. The perioperative outcomes of robot-assisted surgery are superior to the open technique at a comparable oncological follow-up. Even if robot-assisted interventions are often more expensive than laparoscopic surgery due to higher costs of acquisition, robotics have the potential to gain superior results especially in very complex tumor surgery. Due to expiring patent protections, new manufacturers and the development of new technologies, the market of robotic surgery will most likely undergo significant changes and its costs will probably decrease within the next years.