Learning Curve in Robot-assisted Kidney Transplantation: Results from the European Robotic Urological Society Working Group.

Abstract:

BACKGROUND:Recently, robot-assisted kidney transplantation (RAKT) was recently introduced as renal replacement mini-invasive surgery. OBJECTIVE:To report surgical technique, including tips and tricks, and the learning curve for RAKT. DESIGN, SETTING, AND PARTICIPANTS:All consecutive RAKTs performed in the five highest-volume centers of the European Robotic Urological Society RAKT group were reviewed, and a step-by-step description of the technique was compiled. SURGICAL PROCEDURE:Surgeries were performed with Da Vinci Si/Xi. The patient was placed in the lithotomy position. The Trendelenburg position was set at 20-30° and the robot was docked between the legs. MEASUREMENTS:Shewhart control charts and cumulative summation (CUSUM) graphs and trifecta were generated to assess the learning curve according to rewarming time (RWT), intra/postoperative complications, and renal graft function (glomerular filtration rate) on days 7 and 30, and at 1 yr. Linear regressions were performed to compare the learning curves of each surgeon. RESULTS AND LIMITATIONS:Arterial anastomosis time was below the alarm/alert line in 93.3%/88.9% of RAKTs, while venous anastomosis time was below the alarm/alert line in 88.9%/73.9%. The nonanastomotic RWT exceeded +3 standard deviation (SD) in 24.7% of procedures and +2SD in 37.1%. In only 46% cases, the RWT was below the alert line. The ureteroneocystostomy time was below +2SD and +3SD in 87.9% and 90.2% of cases, respectively. CUSUM showed that the learning curve for arterial anastomosis required up to 35 (mean = 16) cases. Complications and delayed graft function rates decreased significantly and reached a plateau after the first 20 cases. Trifecta was achieved in 75% (24/32) of the cases after the first 34 RAKTs in each center. CONCLUSIONS:A minimum of 35 cases are necessary to reach reproducibility in terms of RWT, complications, and functional results. PATIENT SUMMARY:Robot-assisted kidney transplantation requires a learning curve of 35 cases to achieve reproducibility in terms of timing, complications, and functional results. Synergy between the surgeon and the assistant is crucial to reduce rewarming time. High-grade complications and delayed graft function are rare after ten surgeries. Hands-on training and proctorship are highly recommended.

journal_name

Eur Urol

journal_title

European urology

authors

Gallioli A,Territo A,Boissier R,Campi R,Vignolini G,Musquera M,Alcaraz A,Decaestecker K,Tugcu V,Vanacore D,Serni S,Breda A

doi

10.1016/j.eururo.2019.12.008

subject

Has Abstract

pub_date

2020-08-01 00:00:00

pages

239-247

issue

2

eissn

0302-2838

issn

1873-7560

pii

S0302-2838(19)30947-9

journal_volume

78

pub_type

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