Mottrie A, De Naeyer G, Schatteman P, et al. Impact of the learning curve on perioperative outcome in patients who underwent robotic partial nephrectomy for parenchymal tumours. Eur Urol 2010; 58: 127-33.
In a nutshell
This is a single centre trial evaluating the learning curve for Robotic Partial Nephrectomy (RAPN) over a three-year period. Sixty-two consecutive patients underwent transperitoneal RAPN for parenchymal renal tumours using the da Vinci Surgical System. Data were collected prospectively and included perioperative outcomes such as operative times and warm ischaemia times (WIT), blood loss, overall complications and renal function impairment. Prior to surgery, patients had either a magnetic resonance imaging scan or a 3D computed tomography scan to define clinical stage, anatomical characteristics of the tumour and the presence of any accessory vessels.
The surgery was carried out by a single surgeon with considerable experience in robotic surgery and a background of having performed 15 laparoscopic partial nephectomies before the study began. The mean tumour size was 2.8 +/- 1.3cm. Histologic subtypes were angiomyolipoma (8.1%), oncocytoma (14.5%), clear cell renal cell carcinoma (RCC) (50%), papillary RCC (21%) and chromophobe RCC (6.5%). The median console time was 90 minutes (interquartile range: 63-116). Mean warm ischaemia time (WIT) was 20 +/- 7 mins (range: 9-40) and overall perioperative complications were reported in 16.1% of cases. WIT (<20 mins) and console times were optimised after the first 30 cases (p<0.001). Pathologic stage was pT1a in (89.6%), pT1b (10.4%) and there was a positive surgical margin rate of 2%. The postoperative creatinine value was slightly higher in comparison with the mean baseline value (p<0.01).
Second opinion
This is a small trial evaluating an initial experience of RAPN in the hands of an experienced robotic surgeon. The authors admit that it was difficult to identify ideal parameters and criteria to evaluate the initial experience with this new surgical procedure. The conclusions of the study were that RAPN requires a short learning curve to reach WIT <20 minutes, console times <100 minutes, limited blood loss, and acceptable overall complication rates. These results are impressive and contrast with laparoscopic partial nephrectomy (LPN), which is considered a technically challenging procedure. LPN requires a long learning curve in order to reach an acceptable perioperative complication rate and WIT.
It is a non-randomised single centre study with a limited number of patients, and is probably not applicable to centres with much less experience in robotic surgery. RAPN is also expensive and this will limit its use. However, a randomised prospective study comparing LPN with RAPN would prove most useful.
The verdict
- Nephron-sparing surgery is currently the ‘gold standard’ for treatment of renal tumours ?4cm.
- RAPN can be considered the natural evolution and simplification of traditional LPN
- RAPN is a viable option for nephron sparing surgery in patients with renal cell carcinoma.
- RAPN requires a short learning curve to reach WIT <20mins, console times <100mins and acceptable overall complication rates.
John P O’Donoghue
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Jeremy P Crew
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