Cumulative Sum Analysis of the Operator Learning Curve for Robot-Assisted Mayo Clinic Level I–IV Inferior Vena Cava Thrombectomy Associated with Renal Carcinoma: A Study of 120 Cases at a Single Center

Abstract

Departmental sources Background:This study aimed to use cumulative sum analysis of the operator learning curve for robot-assisted Mayo Clinic level I-IV inferior vena cava (IVC) thrombectomy associated with renal carcinoma, and describes the development of an optimized operative procedure at a single center. Material/Methods:A retrospective study included 120 patients with Mayo Clinic level I-IV IVC thrombus who underwent robotic surgery between 2013 and 2018. Points in the learning curve were identified using cumulative sum analysis, and their impact was assessed by multiple regression analysis. Perioperative indicators analyzed included operative time, estimated blood loss, early complications, and the 90-day progression rate. Results:Cumulative sum analysis identified three phases in the learning curve of robot-assisted IVC thrombectomy. The median operative time decreased from 265 min (range, 212-401 min) to 207 min (range, 146-276 min) (p=0.003), the median estimated blood loss decreased from 775 ml (range, 413-1500 ml) to 300 ml (range, 163-813 ml) (p=0.006), and the early complication rate decreased from 52.5% to 15.0% (p<0.001). Multivariate analysis showed that for an initial 40 cases and a further 80 cases, the learning phase, the affected side, the Mayo Clinic level, and the surgical method were independent factors that affected operative time, estimated blood loss, and the rate of early complications. Conclusions:Experience from an initial 40 cases and a further 80 cases of Mayo Clinic level I-IV IVC thrombectomy associated with renal carcinoma were found to provide acceptable surgical and clinical outcomes.

A Decade of Robotic-Assisted Radical Nephrectomy with Inferior Vena Cava Thrombectomy: A Systematic Review and Meta-Analysis of Perioperative Outcomes

“…Only 1 study reported on predictors of perioperative outcomes following R-CT. In a study of 120 cases, Shen et al identified greater thrombus length, a higher level of thrombus (III–IV), and early surgical learning phase (as defined by first 40 cases) to be independent predictors of operative time and blood loss in R-CT. 36 They also reported IVC wall resection (cavectomy), III–IV thrombus and an early surgical learning phase to be independent predictors of early postoperative complications.…”

“…Table 1 summarizes the various case reports and case studies reporting outcomes of R-CT. A total of 21 studies were included. 10,21–40 All the studies were published in English except for 1, for which an English translation was retrieved. 33 Eight (38.1%) of the 21 single-arm studies were case reports involving 1 or 2 patients, and 9 (42.9%) included more than 10 patients.…”

A modified sequential vascular control strategy in robot‐assisted level III–IV inferior vena cava thrombectomy: initial series mimicking the open ‘milking’ technique principle

“…However, our present results showed that there were no significant differences in operating time or blood loss between the cohorts. Our recent research on the LC of RA‐IVCTE also proved that the LC began to enter a stable improvement period after the initial 40 cases [38]. For level III–IV RA‐IVCTE the inflexion point would be delayed accordingly.…”

Step-by-step and orderly lowering of the height of inferior vena cava tumor thrombus is the key to robot-assisted thrombectomy for Mayo III/IV tumor thrombus

“…The multidisciplinary team in which the author works has accumulated a wealth of experience in using robotic surgery for this kind of tumor thrombus. Clinical practice prompts robot-assisted thrombectomy for high IVCTT to be safe and feasible [ 14 , 20 – 22 ]. Robotic surgery significantly reduces injury compared to the surgical approach.…”

“…Although robotic surgery has been proven to be technical feasible, there is a shortage of clinical reports [ 11 , 12 ]. Moreover, most of the articles focus on level III tumor thrombus, and only our center has reported on level IV tumor thrombus [ 2 , 13 , 14 ]. Most studies lack a detailed description of the operation technology and repeatability of the methods, especially in the high inferior vena cava dissociation, suspension, occlusion and thrombectomy.…”