Does teaching of robotic partial nephrectomy affect renal function and perioperative outcomes?

PURPOSE: Partial nephrectomy (PN) represents the treatment of choice for localized renal tumor<7cm. Minimally invasive approaches are considered standard of care in many institutions. Maintaining acceptable warm ischemic time (WIT) while teaching robotic PN (RPN) remains challenging. The goal of the present study was to assess the effect of teaching RPN on WIT and renal function in patients undergoing RPN. METHODS: Patients undergoing RPN for cT1-T2 renal tumors were included. RENAL nephrometry score was used to adjust for tumor complexity. Glomerular filtration rates (GFR) were determined preoperatively, at day 2 and at ≥3-month follow-up. Patients in whom the attending surgeon (staff) performed tumorectomy and renorraphy were compared with those in whom the fellow performed these steps. Primary outcomes were WIT and GFR decrease at follow-up visit. Morbidity and margin positivity represented secondary outcomes. RESULTS: Overall, 69 patients (46 "staff" vs. 23 "fellow") were included. Patient׳s characteristics did not differ significantly between the 2 groups. In particular, RENAL score and preoperative GFR were similar between both groups. Mean WIT was 22±9 in the staff and 24±7 in the fellow group (P = 0.09). At follow-up, a GFR reduction of 9% was observed in the staff group vs. 13% in the fellow group (P = 0.38). Complication rates (13% vs. 17%, P = 0.63) and positive margins (9% vs. 4%, P = 0.47) did not differ significantly between staff and fellow. CONCLUSIONS: In our experience, teaching RPN with a strict supervision and stepwise standardized procedure was oncologically and functionally safe after 3 to 6 months of follow-up.

Is there a place for virtual reality simulators in assessment of competency in percutaneous renal access?

OBJECTIVE: To assess competency of urology post-graduate trainees (PGTs) in percutaneous renal access (PCA). METHODS: Upon obtaining ethics approval and informed consents, PGTs between post-graduate years (PGY-3 to PGY-5) from all four urology programs in Québec were recruited. PCA competency of each participant was assessed objectively by performing task 4 on the PERC Mentor™ simulator, where they had to correctly access and pop 7 balloons in 7 different renal calyces and subjectively by the validated Percutaneous Nephrolithotomy-Global Rating Scale (PCNL-GRS). RESULTS: A total of 26 PGTs with a mean age of 29.2 ± 0.7 years participated in this study. When compared with the 21 PGTs without practice, all 5 PGTs who had practiced on the simulator were competent (p = 0.03), performed the task with significantly shorter operative time (13.9 ± 0.7 vs. 4.4 ± 0.4 min; p < 0.001) and fluoroscopy time (9.3 ± 0.6 vs. 3.4 ± 0.4 min; p < 0.001), and had significantly higher PCNL-GRS scores (13 ± 0.6 vs. 20.6 ± 1; p < 0.001) and successful attempts to access renal calyces (23 ± 5 vs. 68.7 ± 11; p = 0.001). According to a pass score of 13/25, thirteen PGTs were competent. Competent PGTs performed the task with significantly shorter fluoroscopy time (9.8 vs. 6.5 min; p = 0.01) and higher percentage of successful attempts to access renal calyces (p < 0.001), higher PCNL-GRS scores (p < 0.001), and lower complications (p = 0.01). CONCLUSION: The PCNL-GRS in combination with the PERC Mentor™ simulator was able to differentiate between competent and non-competent PGTs.