Transition From Open and Laparoscopic to Robotic Partial Nephrectomy: Learning Curve and Outcomes

摘要

Introduction Partial nephrectomy (PN) is the current standard of care for patients with T1 renal tumors, and there has been a shift from an open and laparoscopic to a robot-assisted approach. The definition of the learning curve for robot-assisted PN (RAPN) is unclear, and various studies have identified warm ischemia time (WIT), perioperative complications, and surgical margins as the defining parameters for the assessment of improvement in these outcomes over time. The objective of this study was to evaluate the learning curve of a newly trained urologist for RAPN when comparing both open and laparoscopic approaches. Methods This study included 52 patients who underwent PN by open, laparoscopic, and robotic methods performed by a single, newly trained urologist over a period of seven years. Basic demographic and perioperative data were collected, and the learning curve was compared between the three approaches. Results Baseline parameters were similar for open (n = 15), laparoscopic (n = 12), and robotic (n = 25) PN except for tumor size and nephrometry score, which were higher in the open group (p = 0.000). Operative time was significantly longer in the robotic approach (180 minutes; p = 0.05), and blood loss was greater in the open group (450 mL; p = 0.000). Median WIT was 25 minutes; significant complications (Clavien Dindo ≥II) and positive surgical margins were 12% and 0%, respectively, in the robotic arm. Preoperative imaging and final histopathology data showed larger tumors being operated on, preferably by an open method, than laparoscopic and robotic PN (6.3 cm vs. 3.4 cm; p = 0.000). More open and laparoscopic procedures (n = 12, 10) were performed during the initial 26 cases, with a later transition to robot-assisted PN (n = 21) in the next 26 cases. None of the parameters showed improvement in the latter half, while operative time showed an increase (150 vs. 180 minutes; p = 0.045). Conclusion The learning curve becomes similar across three defined parameters, i.e., WIT, perioperative complications, and positive surgical margins, after performing a minimum of 25 RAPNs when compared to open and laparoscopic approaches. However, operative duration continues to improve and may take longer to become comparable. A newly trained urologist can safely perform RAPNs even with a small number of cases, especially those who have been previously trained for open and laparoscopic cases.