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The ERUS curriculum for robot-assisted partial nephrectomy: structure definition and pilot clinical validation

  • Alessandro Larcher,
  • Geert De Naeyer,
  • Filippo Turri,
  • Paolo Dell’Oglio,
  • Umberto Capitanio,
  • Justin W. Collins,
  • Peter Wiklund,
  • Henk Van Der Poel,
  • Francesco Montorsi,
  • Alexandre Mottrie

Publication: European Urology, Volume 75, Issue 6, June 2019, Pages 1023-1031





Background

No validated training program for robot-assisted partial nephrectomy (RAPN) exists.

Objective

To define the structure and provide a pilot clinical validation of a curriculum for robot-assisted partial nephrectomy (RAPN).

Design, setting, and participants

A modified Delphi consensus methodology involving 27 experts defined curriculum structure. One trainee completed the curriculum under the mentorship of an expert. A total of 40 patients treated with curriculum RAPN (cRAPN) were compared with 160 patients treated with standard of care (sRAPN).

Outcome measurements and statistical analysis

To define curriculum structure, consensus was defined as ≥90% expert agreement. To investigate curriculum safety, perioperative morbidity, renal function, and pathologic outcomes were evaluated. To investigate curriculum efficacy, RAPN steps and modules attempted and completed by the trainee were evaluated. Propensity score matching identified comparable cRAPN and sRAPN cases. Mann–Whitney U test, chi-square test, and linear regression were used to investigate the impact of the curriculum on patient’s outcome and the impact of trainee’s experience on surgical independence.

Results and limitations

Consensus-based key statements defined curriculum structure. No difference was recorded between cRAPN and sRAPN with respect to intraoperative or overall and grade-specific postoperative complications, blood loss, ischemia time, postoperative estimated glomerular filtration rate, and positive surgical margins (all p > 0.05). Conversely, operative time was longer after cRAPN (p < 0.0001). The trainee completed all phases of the curriculum and the trainee’s experience was associated with more steps attempted/completed and increasing complexity of module attempted/completed (all p < 0.0001). The limitations of the study are the enrolment of a single trainee at a single institution and the small sample size. Accordingly, the large confidence intervals observed cannot exclude inferior outcomes in case of cRAPN and further study is required to confirm safety.

Conclusions

The European Association of Urology (EAU) Robotic Urology Section (ERUS) curriculum for RAPN can protect patients from suboptimal outcome during the learning curve of the surgeon and can aid surgeons willing to start an RAPN program.

Patient summary

Patients should be aware that structured training programs can reduce the risk of suboptimal outcome due to the learning curve of the surgeon.