Hand-assisted partial nephrectomy with early arterial clamp removal: Impact of the learning curve

Background: Urology has been at the forefront of adopting laparoscopic and robot-assisted techniques to improve patient outcomes. This systematic review aimed to examine the literature relating to the learning curves of major urological robotic and laparoscopic procedures. Methods: In accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, a systematic literature search strategy was employed across PubMed, EMBASE, and the Cochrane Library from inception to December 2021, alongside a search of the grey literature. Two independent reviewers completed the article screening and data extraction stages using the Newcastle–Ottawa Scale as a quality assessment tool. The review was reported in accordance with AMSTAR (A MeaSurement Tool to Assess systematic Reviews) guidelines. Results: Of 3702 records identified, 97 eligible studies were included for narrative synthesis. Learning curves are mapped using an array of measurements including operative time (OT), estimated blood loss, complication rates as well as procedure-specific outcomes, with OT being the most commonly used metric by eligible studies. The learning curve for OT was identified as 10–250 cases for robot-assisted laparoscopic prostatectomy and 40–250 for laparoscopic radical prostatectomy. The robot-assisted partial nephrectomy learning curve for warm ischaemia time is 4–150 cases. No high-quality studies evaluating the learning curve for laparoscopic radical cystectomy and for robotic and laparoscopic retroperitoneal lymph node dissection were identified. Conclusion: There was considerable variation in the definitions of outcome measures and performance thresholds, with poor reporting of potential confounders. Future studies should use multiple surgeons and large sample sizes of cases to identify the currently undefined learning curves for robotic and laparoscopic urological procedures.

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“…Three studies 19 , 89 , 94 assessed the learning curve for hand-assisted laparoscopic nephrectomy. Azawi et al .…”

Section: Resultsmentioning

confidence: 99%

“…Azawi et al . 89 reported achievement of 5 min or less WIT after 40 procedures due to the safe and easily learned procedural step of early arterial clamp removal.…”

Section: Resultsmentioning

confidence: 99%

The learning curves of major laparoscopic and robotic procedures in urology: A systematic review

Chahal

Aydın

Amin

et al. 2023

International Journal of Surgery

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“…However, HALPN is known to be safe and easy to learn. Azawi et al [19] presented their outcome of HALPN with early removal of the arterial clamp. The authors demonstrated that HALPN with early removal of the arterial clamp is safe and easy to perform; thus, it is believed that a laparoscopic surgeon who had performed 40 procedures can obtain a warm ischemic time of 5 minutes or less.…”

Section: Discussionmentioning

confidence: 99%

Selective clamping hand-assisted laparoscopic partial nephrectomy for localized renal tumors: A novel technique

et al. 2019

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Purpose In this study, we described our initial experience and analyze the learning curve of segmental renal artery branch clamping with hand-assisted laparoscopic partial nephrectomy (PN) using special instruments. Materials and Methods We conducted a retrospective review of consecutive cases of hand-assisted laparoscopic PN (LPN) between May 2015 and April 2018. Patient demographics, tumor characteristics, perioperative details, postoperative complications, and warm ischemic time for segmental artery branch clamping were included in our analysis. We used the cumulative sum (CUSUM) method to generate learning curves. Results Segmental renal artery branch clamping was successfully completed in 16 of 20 patients. The median tumor size was 2.9 cm (range, 1.7–7.0 cm), median operation time was 185 minutes (range, 140–245 minutes), median blood loss was 291 mL (range, 100–600 mL), and median hospital stay was 5 days (range, 4–7 days). The median selective ischemic time was 21 minutes (range, 16–35 minutes). No patient had postoperative complications, acute or delayed bleeding. The median pre- and postoperative serum creatinine levels (0.91 and 0.98 mg/dL, respectively), and the pre- and postoperative estimated glomerular filtration rate (89.7 and 79.6 mL/min per 1.73 m 2 , respectively) were similar. Upon visual assessment of the CUSUM plots, a downward inflection point for decreasing total operation time was observed in the 9th case and estimated blood loss in the 12th case. Conclusions Our study shows that segmental renal artery branch clamping hand-assisted LPN for localized renal tumors is feasible, safe, and has a relatively short learning curve.

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“…No difference between hand-assisted and pure laparoscopic technique was seen in order to achieve all three components of our Trifecta. Azawi [27] studied the impact of using a hand-assisted technique on the learning curve and found that the surgeon must perform 40 procedures to obtain a WIT of five minutes. Our The nomogram from our study should to be tested on multicenter cohorts in order to externally validate and generalize our findings.…”

Section: Ebl Is the First Component In Our Definition And Intraoperative Hemorrhagementioning

confidence: 99%

Prediction of Intraoperative Trifecta Achievement during Laparoscopic Partial Nephrectomy

Tysland¹,

Barnoiu²,

Barón³

et al. 2021

OJU

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Purpose: We introduce the concept of intraoperative Trifecta during laparoscopic partial nephrectomy (LPN) as the simultaneous achievement of estimated blood loss (EBL) < 500 ml, warm ischemia time (WIT) < 20 minutes and minimal changes of the intraoperative course. The study's aim was to find preoperative factors that could predict the likelihood of achieving intraoperative Trifecta and build a surgical nomogram. Methods: We retrospectively evaluated 122 patients who underwent LPN. Preoperative factors like age, sex, body-mass index (BMI), kidney function, tumor characteristics (R.E.N.A.L. score) and Charlson-Comorbidity-Index (CCI) were recorded. Intraoperative complication (IOC) was graded according to the Rosenthal classification. R software was used to find a predicting model for achievement of Trifecta using preoperative variables and a nomogram was built. Results: The surgical features include median EBL of 100 ml having 6.5% bleed > 500 ml, median WIT of 12 minutes having 7.3% more than 20 minutes. There was recorded a 12.3% IOC with a mean Rosenthal's grade of 0.2. Intraoperative Trifecta was achieved in 105 patients (86%) and three preoperative factors were chosen for the predictive model: BMI (p = 0.041), CCI (p = 0.037) and RENAL score (p = 0.002). A nomogram was generated and the ROC-AUC of the model was 75.8%. Conclusion: We have defined an intraoperative Trifecta concept as the achievement of EBL < 500 ml, WIT < 20 minutes and minimal changes of the intraoperative course. A nomogram was developed from preoperative factors like BMI, CCI and R.E.N.A.L. score. It can be used to estimate the probability of Trifecta achievement in patients treated with LPN.

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Hand-assisted partial nephrectomy with early arterial clamp removal: Impact of the learning curve

Cited by 7 publications

References 18 publications

The learning curves of major laparoscopic and robotic procedures in urology: A systematic review

The learning curves of major laparoscopic and robotic procedures in urology: A systematic review

Selective clamping hand-assisted laparoscopic partial nephrectomy for localized renal tumors: A novel technique

Prediction of Intraoperative Trifecta Achievement during Laparoscopic Partial Nephrectomy

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