Additionally, the precision afforded by robotic assistance can enhance the surgeon's ability to perform delicate dissections and reconstructions, potentially preserving more of the healthy renal tissue and thus maintaining better overall kidney function. The technological advancements in these procedures also facilitate improved visualization of the surgical field, allowing for more accurate and controlled removal of renal tumors. This is particularly beneficial in complex cases where the tumor's location and the patient's anatomy present challenges. Consequently, laparoscopic and RAPN have become preferred methods for treating localized kidney tumors, offering patients faster recovery times and better functional outcomes compared to conventional open surgery.
The learning curve for partial nephrectomy represents the process of gaining expertise in performing the surgical procedure over time. It takes considerable time and practice to develop the necessary skills to perform a successful partial nephrectomy with minimal complications.2 Evidence from prior studies indicated that peri-operative outcomes, including complications and ischemia time, improved with increased surgical experience,2 but data on the potential impact of surgeon experience on functional outcomes after surgery is still scarce. In particular, a relationship between acute kidney injury (AKI), a sudden episode of kidney failure that might happen after kidney surgery and long-term consequences such as chronic kidney disease has been established.3
Given the complexity of partial nephrectomy, understanding the nuances of the learning curve is crucial for improving patient outcomes. Surgeons gradually enhance their technical skills and decision-making abilities through repeated practice and exposure to various surgical scenarios. This gradual improvement has been documented to lead to better peri-operative outcomes, highlighting the importance of experience. In this context, it has been demonstrated that early functional impairment after surgery – i.e. AKI – is correlated with long-term renal function after partial nephrectomy,3 but whether surgical experience might affect both AKI or long-term function after partial nephrectomy remains unknown. For this reason, we relied on a multi-institutional database including multiple surgeons to investigate the association between surgical experience and functional outcomes in patients undergoing laparoscopic and robot-assisted partial nephrectomy (RAPN).
We retrospectively analyzed data of 4,011 patients with a single, unilateral cT1a-b renal mass treated with laparoscopic or robot-assisted partial nephrectomy. Operations were performed by 119 surgeons at 22 participating institutions between 1997 and 2022. Multivariable models investigated the association between surgical experience (number of prior operations) and acute kidney injury (AKI) and recovery of at least 90% of baseline estimated glomerular filtration rate (eGFR) 1 yr after partial nephrectomy. The adjustment for case-mix included age, Body Mass Index, preoperative serum creatinine, clinical T stage, PADUA score, warm ischemia time, pathologic tumor size, and year of surgery.
A total of 753 (19%) and 3258 (81%) patients underwent laparoscopic and robot-assisted partial nephrectomy, respectively. Overall, 119 unique surgeons were included in the study. Of them, 37 (31%) and 55 (46%) contributed only to laparoscopic and robotic learning curves, respectively, whereas 27 (23%) contributed to both approaches. Approximately half of surgeons included in both groups had done fewer than 50 cases in their career, whereas 6 (9%) and 14 (16%) surgeons had done more than 250 laparoscopic and robotic procedures, respectively.
Laparoscopic partial nephrectomy. Renal masses treated by more experienced surgeons were bigger and more complex. The rate of off-clamp procedures was higher for more experienced surgeons (77% vs. 41% for cases done by surgeons with ≥150 vs. <50 prior laparoscopic partial nephrectomies).
A total of 61 (8%) patients developed AKI after surgery. Among those with available data on renal function one year after surgery (n=444), 245 (55%) patients recovered at least 90% of their baseline eGFR. After adjusting for confounders, we did not find evidence of an association between surgical experience and acute kidney injury after laparoscopic partial nephrectomy (Odds ratio [OR]: 0.9992; 95% confidence interval [CI]: 0.9963, 1.0022; p=0.6). Similar results were found when 1-year renal function was the outcome of interest (OR: 0.9996; 95%CI: 0.9988, 1.0005; p=0.5; Figure 1).
Figure 1. Probability of Recovering at least 90% of Baseline eGFR After Laparoscopic Partial Nephrectomy over Surgical Experience (Number of Prior Operations). Dashed Lines Are 95% Confidence Interval.
Robot-assisted partial nephrectomy. While baseline characteristics were quite similar between the groups, as compared to less experienced surgeons, the rate of on-clamp procedures was higher in the more experienced group (81% vs. 76% for surgeons with ≥150 vs. <50 prior RAPNs; p=0.015), whereas the duration of ischemia was shorter (median: 15 vs. 16 minutes; p<0.0001).
Acute kidney injury after surgery occurred in 369 (11%) patients. Among 1521 patients with available data on one-year renal function, 828 (54%) recovered at least 90% of their baseline eGFR. On multivariable logistic regression, the relationship between surgical experience and AKI after surgery was not statistically significant (OR: 1.0015; 95%CI: 0.9992, 1.0037; p=0.2). We found similar results when the outcome of interest was renal function one year after surgery (OR: 1.0001; 95%CI: 0.9980, 1.0022; p=0.9; Figure 2).
Figure 2. Probability of Recovering at least 90% of Baseline eGFR After Robot-Assisted Partial Nephrectomy over Surgical Experience (Number of Prior Operations). Dashed Lines Are 95% Confidence Interval.
In conclusion, in this large, multi-institutional project involving several surgeons, we did not find evidence of an association between functional recovery after partial nephrectomy – laparoscopic or robot-assisted – and the number of prior operations performed by the surgeon at index patient surgery. As such, our findings suggest that surgical experience may not significantly impact functional recovery following partial nephrectomy. While potential explanations include the use of serum creatinine as a marker of functional recovery in patients with two kidneys, it is important to investigate what are the key steps of the procedure that allowed novices to have comparable outcomes as compared to more experienced surgeons. These represent the main focus for future educational efforts and should be taken into account during training and proctoring surgeons who start their practice in laparoscopic or robot-assisted partial nephrectomy.
Written by: C.A. Bravi,1,2,3,4 P. Dell’Oglio,5,6,7 A. Pecoraro,8 Z.E. Khene,9 R. Campi,10 P. Diana,11 C. Re,4,12 C. Giulioni,13,14 A.T. Beksac,15 R. Bertolo,16 T. Ajami,17 K.E. Okhawere,18 M. Meagher,19 A. Alimohammadi,20 M. Borghesi22, A. Mari,23 D. Amparore,24 M. Roscigno,25,32 U. Anceschi,26 G. Simone,26 N. Suardi,27 A. Galfano,5 R. Schiavina,28 F. Dehó,12 K. Bensalah,9 A.E. Canda,29,33 V. Ferrara,13 A. Alcaraz,17 X. Zhang,30 C. Terrone,22 S. Shariat,20,21 F. Porpiglia,24 A. Antonelli,31 J. Kaouk,15 K. Badani,18 A. Minervini,23 I. Derweesh,19 A. Breda,11 A. Mottrie,2,3 F. Montorsi,4 A. Larcher4
- Department of Urology, The Royal Marsden NHS Foundation Trust, London, United Kingdom
- Department of Urology, Onze-Lieve-Vrouwziekenhuis Hospital, Aalst, Belgium
- ORSI Academy, Ghent, Belgium
- Division of Oncology/Unit of Urology; URI; IRCCS Ospedale San Raffaele, Milan, Italy
- Department of Urology, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy;
- Department of Urology, Antoni van Leeuwenhoek Hospital, The Netherlands Cancer Institute, Amsterdam, The Netherlands;
- Interventional Molecular Imaging Laboratory, Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
- Department of Urology, Hospital Pederzoli, Peschiera del Garda, Verona, Italy.
- Department of Urology, University of Rennes, Rennes, France.
- Unit of Urological Robotic Surgery and Renal Transplantation, Careggi Hospital, University of Florence, Florence, Italy; Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
- Department of Urology, Fundació Puigvert, Autonoma University of Barcelona, Barcelona, Spain.
- ASST-Sette Laghi, Circolo & Fondazione Macchi Hospital, University of Insubria, Varese, Italy.
- Unit of Urology, Jesi Hospital, Jesi, Ancona, Italy.
- Department of Urology, Polytechnic University of Marche Region, Ancona, Italy.
- Glickman Urological & Kidney Institute, Cleveland Clinic, Cleveland, OH.
- Department of Urology, San Carlo Di Nancy Hospital, 00165 Rome, Italy.
- Department of Urology. Hospital Clinic-IDIBAPS. University of Barcelona, Barcelona, Spain.
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York City, NY, USA.
- University of California, San Diego, La Jolla, California.
- Department of Urology, Medical University of Vienna, Vienna, Austria
- Institute for Urology and Reproductive Health, Sechenov University, Moscow, Russia
- Department of Surgical and Diagnostic Integrated Sciences (DISC), University of Genova, Genova, Italy
- Unit of Oncologic Minimally-Invasive Urology and Andrology - Careggi Hospital. Department of Clinical and Experimental Medicine, University of Florence, Florence, Italy.
- Department of Oncology, Division of Urology, University of Turin, San Luigi Gonzaga Hospital, Orbassano (Turin), Italy
- ASST Papa Giovanni XXIII, Bergamo, Italy.
- IRCCS "Regina Elena" National Cancer Institute, Department of Urology, Rome, Italy
- Department of Urology, University of Brescia, Brescia, Italy
- Division of Urology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Koç University Hospital Department of Urology, Istanbul, Turkey
- Department of Urology, Chinese PLA General Hospital, Beijing, China.
- Department of Urology, University of Verona, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
- University of Milano-Bicocca, School of Medicine, Milan, Italy.
- RMK AIMES, Rahmi M. Koç Academy of Interventional Medicine, Education, and Simulation, Istanbul, Turkey
- I. Mihai, H. Dura, C.A. Teodoru, S.B. Todor, C. Ichim, N. Grigore, C.I. Mohor, A. Mihetiu, G. Oprinca, N. Bacalbasa, D. Tanasescu, D.G. Bratu, A. Boicean, B. Oros, A. Hasegan. "Intraoperative Ultrasound: Bridging the Gap between Laparoscopy and Surgical Precision during 3D Laparoscopic Partial Nephrectomies". Diagnostics, 2024 Apr 30;14(9):942. doi: 10.3390/diagnostics14090942.
- A. Larcher, F. Muttin, B. Peyronnet, G. De Naeyer, Z.-E. Khene, P. Dell’Oglio, C. Ferreiro, P. Schatteman, A. Vickers, F. D’Hondt, F. Montorsi, K. Bensalah, and A. Mottrie, “The Learning Curve for Robot-assisted Partial Nephrectomy: Impact of Surgical Experience on Perioperative Outcomes,” European Urology, pp. 1–4, Sep. 2018.
- A. Martini and C. A. Bravi, “Acute kidney injury and functional outcomes after partial nephrectomy,” International Journal of Urology, pp. 1–2, May 2022.