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.

中文翻译：

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机器人辅助肾脏移植的学习曲线：欧洲机器人泌尿外科学会工作组的结果。

背景

最近，机器人辅助肾脏移植（RAKT）最近被引入作为肾脏替代微创手术。

目的

报告外科技术，包括技巧和窍门，以及RAKT的学习曲线。

设计，设置和参与者

审查了在欧洲机器人泌尿外科学会RAKT组的五个容量最大的中心进行的所有连续RAKT，并对该技术进行了逐步描述。

手术程序

手术是用达芬奇·西/西进行的。患者被置于截石位。特伦德伦伯卧位的位置设置为20–30°，并且机器人停靠在两腿之间。

测量

生成Shewhart控制图，累积总和（CUSUM）图和Trifecta，以根据第7天和第30天以及第1天的复温时间（RWT），术中/术后并发症和肾移植功能（肾小球滤过率）评估学习曲线。年。进行线性回归以比较每个外科医生的学习曲线。

结果与局限性

在93.3％/ 88.9％的RAKT中，动脉吻合时间在警报/警报线以下，而在静脉/静脉吻合时间在警报/警报线以下在88.9％/ 73.9％。非吻合手术的RWT在24.7％的手术中超过+3标准偏差（SD），在37.1％的情况下超过+2 SD。在仅46％的情况下，RWT低于警报线。在87.9％和90.2％的病例中，输尿管膀胱造口术时间分别低于+ 2SD和+ 3SD。CUSUM显示，动脉吻合的学习曲线最多需要35例（平均= 16例）。并发症和延迟的移植物功能率显着降低，并在前20例后达到平稳状态。在每个中心的前34个RAKT之后，有75％（24/32）的病例达到了Trifecta。

结论

要在RWT，并发症和功能结果方面达到再现性，至少需要35例。

病人总结

机器人辅助肾移植需要35例学习曲线，以在时间，并发症和功能结果方面实现可重复性。外科医生和助手之间的协同作用对于减少重新加热时间至关重要。十次手术后很少发生高度并发症和移植物功能延迟。强烈建议进行动手训练和指导。