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A Single Surgeon’s First 150 Robotic Partial Nephrectomy Cases: Analysis of the Learning Curve
Kyle T. Finnegan, BS1, Anoop M. Meraney, MD1, Anne M. Suskind, MD2, Stuart S. Kesler, MD1, Steven J. Shichman, MD1.
1Hartford Hospital, Hartford, CT, USA, 2University of Connecticut, Farmington, CT, USA.

Background: Nephron-sparing surgery is considered to be the gold standard for treatment of small renal tumors. Robotic partial nephrectomy (RPN) is a recent addition to the Urologist’s armamentarium for treatment of these tumors. In this study, we analyze a single surgeon’s first 150 RPN’s with focus on the surgical learning curve. To date, this series represents one of the largest single-surgeon robotic series reported.

Methods: A single surgeon at our institution performed 150 RPN’s from October 2007 to April 2010. Data was collected prospectively into an IRB-approved database. Patient age, body mass index (BMI), tumor size, operative time, warm ischemic time (WIT), estimated blood loss (EBL), length of stay (LOS), conversions, complications and margin status were analyzed and compared between two groups: the first 75 and last 75 procedures.

Results: The differences between the two groups were substantial. Significant differences were seen in the following parameters: BMI [27.9 vs. 29.7 k/m2 (p = 0.045)], LOS [3 vs. 3.7 days (p<0.001)], and tumor size [2.5 vs. 2.9 cm (p = 0.021)] between the 1st 75 cases and the subsequent 75 cases. The most clinically important difference was the decline in WIT from 31.4 mins in the first 75 procedures to 22.8 mins in the last 75 procedures (p<0.001). There were 14 complications in the first 75 surgeries (8 Clavien grade I) and only 6 in the last 75 surgeries (5 Clavien grade I). There were no considerable differences in patient age (60.7 vs. 61.1 years), operative time (199.1 vs. 191.7 mins), or EBL (279.6 vs. 319.6 mL) between the two groups. There was only 1 conversion (to Laparoscopic Partial Nephrectomy (LPN)) in the first group and 4 conversions in the second group (3 to open and 1 to LPN). There was 1 positive margin in each group.

Conclusions: Evolutions in surgical technique and added experience over 150 RPN’s have resulted in a significant decrease in WITs and complication rate in the last 75 cases. Improvements in surgical technique include modification of the trocar placement, placing fewer sutures while the vessels are clamped, adding extra sutures after the release of occlusion clamps, and waiting to cut sutures and remove needles until after removal of vascular occlusion clamps. The learning curve for performing RPN’s seems to be quickly overcome despite taking on more complex cases as shown by the increase in patient BMI and tumor size.

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