The laparoscopic nephrectomy learning curve: a single centre’s development of a de novo practice

Abstract

Objective: There has been a dramatic increase in the interest and practice of laparoscopic urology, with nephrectomy having become the commonest laparoscopic urological procedure. Compared with open nephrectomy, it results in reduced morbidity and shorter convalescence times while maintaining oncological safety. However, while these results predominately stem from institutions with well developed laparoscopic programmes, little is known about the results in centres that have newly adopted this technique. The introduction of a laparoscopic urological service at the Royal Hallamshire Hospital provided an opportunity to study these factors. Methods: Since the appointment in October 2000 of a urological surgeon (N Oakley) to develop the laparoscopic service, there have been over 200 laparoscopic procedures including 121 nephrectomies performed at this centre. Full details were collected for each of these cases, and in addition, compared with retrospective data for 50 open nephrectomies performed during the same time period. Results: With increased operator experience the median operative duration, complication, transfusion, and conversion rates significantly improved. While a learning curve was evident, the overall operative complication (9%) and conversion rates (6%) were low, in addition to patient morbidity (16.5%) and mortality (0%) rates, showing that this learning curve had no deleterious effects upon patient care. The median hospital stay was four days, which reduced to three with experience and was significantly shorter than for open nephrectomy at this institution (p = 0.001). Conclusions: The development of a successful laparoscopic programme can be achieved with a comparatively short learning curve and without detriment to the patient provided the necessary steps are observed.

Should oncological cases of upper urinary system be excluded at the beginning of the laparoscopic learning curve?

“…It is quite evident that operative time is not the main determinative criterion for the learning curve. However, operative times shorten or even remain stable after an increase in the number of cases ( 11 ). In their series of 100 cases with laparoscopic nephrectomies, Gill et al estimated mean operative times as 175, and 163 minutes for the first, and the next 50 cases of their series ( 12 ).…”

Defining the Tipping Point in Surgical Performance for Laparoscopic Donor Nephrectomy Among Transplant Surgery Fellows: A Risk-Adjusted Cumulative Summation Learning Curve Analysis

“…Although prior studies have examined the LC of surgical trainees learning LDN , no study to date has comprehensively examined the multimodal metrics of the operation in a single analysis. These studies confirm the inverse relationship between surgeon experience and operative time and the indirect extrapolation to surgical proficiency; however, training and teaching laparoscopic skills involves complex surgical decision making and a rapidly changing intraoperative dynamic that involve a broad set of metrics.…”

How Many Cases Are Necessary to Develop Competence for Laparoscopic Radical Nephrectomy?

“…It is true, however, that the operative time decreases as the number of cases performed increases, and at some point the decline comes to a halt. [12][13][14] Therefore, it is plausible to consider the operative time as one of several significant indicators of the learning curve.…”

“…The number of surgical cases needed to overcome this learning curve is controversial. Phillips and colleagues 13 reported that operative time did not decrease further after the first 20 cases; therefore, it was concluded that the learning curve for laparoscopic nephrectomy was approximately 20 cases. The subjected disease, however, was a different one.…”