Histerectomía laparoscópica en patología benigna en un hospital universitario terciario. Análisis y evolución de un periodo de 8 años / Laparoscopic hysterectomy for benign pathology in a tertiary university hospital: Analysis and evolution in a period of 8 years

Objetivo: Reflexionar desde el análisis de los datos del número de histerectomías laparoscópicas que puede realizar cada miembro de un servicio de ginecología de un hospital terciario sobre la conveniencia de limitar este procedimiento a un número limitado de profesionales. Material y métodos: Estudio retrospectivo, descriptivo, sobre las histerectomías realizadas por cualquier indicación en nuestro hospital en el periodo comprendido entre el 1 de mayo del año 2014 y el 30 de abril del año 2022. Resultados: En este periodo hemos realizado 1548 histerectomías, de las que 760 se efectuaron por vía laparoscópica; y de ellas, 289 fueron indicadas por patología benigna. Considerando el total de profesionales que conforman el pool de cirujanos que realizan cirugía por patología benigna, la media de histerectomías laparoscópicas por cirujano y año sería de 1,4 casos. Conclusiones: Para garantizar la adecuada calidad de la cirugía, el número de profesionales que realizan histerectomías laparoscópicas en un hospital terciario debe ser limitado.(AU)

Objective: To reflect from the analysis of the data of the number of laparoscopic hysterectomies that each member of a gynaecology service of a tertiary hospital can perform on the convenience of limiting this procedure to a limited number of professionals. Material and methods: Retrospective, descriptive study on hysterectomies performed for any indication in our hospital in the period between May 1, 2014 and April 30, 2022. Results: In this period, we have performed 1548 hysterectomies of which 760 were performed laparoscopically and of these, 289 were indicated for benign pathology. Considering the total number of professionals that make up the pool of surgeons who perform surgery for benign pathology, the average number of laparoscopic hysterectomies per surgeon per year would be 1.4 cases. Conclusions: To ensure adequate quality of surgery, the number of professionals performing laparoscopic hysterectomies in a tertiary hospital should be limited.(AU)

Results during the learning curve in the laparoscopic common bile duct exploration for choledocolithiasis.

OBJECTIVES: To analyze the results obtained in terms of efficacy and safety during the learning curve of a surgical team in the technique of laparoscopic common bile duct exploration with cholecystectomy (LCBDE+LC) using choledochoscopy for the treatment of patients with cholelithiasis and choledocolithiasis or common bile duct stones (CBDS) (CDL). METHODS: Single-center prospective analysis of patients treated with LCBDE+LC during the first 4 years of implementation of the technique. A descriptive and comparative analysis was carried out between groups according to the transcystic (TCi) or transcolecocal (TCo) approach, and also evolutionary by periods. The effectiveness of the technique was evaluated using the variable success rate and safety through the analysis of the overall complication rate and the bile leak rate as the most frequent adverse effect. RESULTS: A total of 78 patients were analyzed. The most frequent approach was TCo (62%). The overall success rate was 92%. The TCi group had a shorter operating time, a lower overall complications rate and a shorter hospital stay. The TCo approach was related to a higher rate of clinically relevant bile leak (8%). Complex cases increased significantly during the learning curve without effect on the overall results. CONCLUSIONS: LCBDE+LC is an effective and safe technique during the learning curve. Its results are comparable to those published by more experienced groups and do not present significant differences related to the evolution during learning period.

Starting a robotic thoracic surgery program: From wedge resection to sleeve lobectomy in six months. Initial conclusions / Inicio de un programa de cirugía torácica robótica: de resección en cuña a lobectomía con broncoplastia en seis meses. Conclusiones iniciales

Introduction: Robot-assisted thoracic surgery (RATS) is a rapidly expanding technique. In our study, we aimed to analyze the results of the process to adopt robotic surgery in our Department of Thoracic Surgery. Methods: This is an intention-to-treat analysis of a series of consecutive patients operated on using the RATS approach in our hospital from January 2021 to March 2022. Data were registered for patient characteristics, type of surgery, operative times, conversion rate, chest tube duration, length of hospital stay and complications. The IBM SPSS® statistical software was used for the statistical analysis. A cumulative sum analysis of the operating time was performed to define the learning curve. Results: During the study period, 51 patients underwent robotic surgery, including pulmonary and non-pulmonary interventions. In addition, 15 patients (29.4%) underwent non-pulmonary interventions: one pleural (2%), 2 diaphragmatic (3.9%), and 12 mediastinal (23.5%). Among the mediastinal surgeries, one conversion was necessary (8.3%) for a complex vascular malformation, and 11 were completed by RATS, including 7 (58.3%) thymomas, 3 (25%) pleuro-pericardial cysts, and one (8.3%) neurogenic tumor. Mean operative time was 141 min (104–178), mean chest tube duration was 0.9 days (0–2), and mean length of stay was 1.45 days (1–2). Thirty-six patients underwent lung surgery (70.6%). The complete RATS resections (34; 94.4%) included: 3 wedge resections (11.1%), 2 segmentectomies (3.7%), 28 lobectomies (81.5%), and one sleeve lobectomy (3.7%). Mean surgery time was 194.56 min (141–247), chest tube duration was 3.92 days (1–8), and length of stay was 4.6 days (1–8). Complications occurred in 4 patients (11.1%). No 90-day mortalities were registered. (AU)

Introducción: La cirugía torácica asistida por robot (RATS) es una técnica en rápida expansión. Nuestro objetivo fue analizar el resultado del proceso de adopción de la cirugía robótica en nuestro Departamento de Cirugía Torácica. Métodos: Este es un análisis por intención de tratamiento de una serie de pacientes consecutivos operados mediante el método RATS en nuestro centro desde enero de 2021 a marzo de 2022. Se registraron las características de los pacientes, tipo de cirugía, tiempos operatorios, tasa de conversión, duración del drenaje torácico, estancia hospitalaria y complicaciones. Para el análisis estadístico se utilizó el software IBM SPSS®. Se realizó un análisis de suma acumulada del tiempo de operación para definir la curva de aprendizaje. Resultados: Durante el periodo de estudio, 51 pacientes fueron sometidos a cirugía robótica.15 pacientes (29,4%) fueron sometidos a intervenciones no pulmonares: 1 pleural (2%), 2 diafragmáticas (3,9%) y 12 mediastínicas (23,5%). Entre las cirugías mediastínicas, fue necesaria una conversión (8,3%) por malformación vascular compleja y 11 fueron completadas por RATS, incluidos 7 (58,3%) timomas, 3 (25%) quistes pleuro-pericárdicos y 1 (8,3%) tumores neurogénicos. El tiempo operatorio medio fue de 141 minutos [104–178], la duración media del tubo torácico fue de 0,9 días [0–2] y la estancia media fue de 1,45 días [1–2]. 36 pacientes tuvieron cirugías pulmonares (70,6%). Las resecciones RATS completas (34; 94,4%) incluyeron: 3 resecciones en cuña (11,1%), 2 segmentectomías (3,7%), 28 lobectomías (81,5%) y 1 lobectomía con broncoplastia (3,7%). El tiempo medio de cirugía fue de 194,56 minutos [141–247], la duración del tubo torácico fue de 3,92 días [1–8] y la estancia hospitalaria fue de 4,6 días [1–8]. No se registró mortalidad a los 90 días. (AU)

Curva de aprendizaje para el acceso con trocar óptico en cirugía pélvica laparoscópica: estudio prospectivo / Learning curve of optical trocar access during laparoscopic pelvic surgery: A prospective study

Introducción El acceso con trocar óptico (ATO) es una técnica modificada de laparoscopia cerrada cuyo objetivo es minimizar el riesgo de lesiones vasculares o intestinales y reducir la posible fuga de gas. Se ha analizado el efecto de la curva de aprendizaje (CA) para el ATO, considerando n=30 procedimientos como umbral para definir un nivel aceptable de experticia. Nuestro objetivo es evaluar el impacto de la CA en los primeros 30 casos de ATO realizados por un aprendiz. Métodos Se trata de un estudio prospectivo aleatorizado en 60 pacientes planificadas para cirugía ginecológica laparoscópica. Las pacientes fueron seleccionadas aleatoriamente para el ATO realizado por un cirujano sin entrenamiento previo en la técnica o por un cirujano experto. La CA se evaluó mediante: 1) tiempo hasta lograr el acceso; 2) número de correcciones hechas por el experto; 3) número de veces en que la punta del trocar se detuvo en la capa preperitoneal; 4) errores al realizar la incisión en la piel; 5) veces en que la punta del trocar termina bajo el epiplón; 6) complicaciones. Para analizar el CA en los 30 primeros casos, se estratificaron los procedimientos en 3 grupos (casos 1-10; 11-20; 21-30) tanto para el aprendiz como para el experto y se compararon las variables de la CA. Resultados De forma global, el tiempo medio de inserción para el ATO fue de 56s. No se registraron complicaciones intraoperatorias ni postoperatorias graves. El tiempo medio de inserción fue estadísticamente más largo para el aprendiz en comparación con el experto en los 10 primeros casos (91s frente a 33s, respectivamente, p=0,01). En los casos 11-20 y 21-30, la ventaja de tiempo del cirujano experto se hizo menos evidente (p=0,05). El número de veces que la punta del trocar se detuvo en la capa preperitoneal fue similar entre los grupos, así como las veces que la punta del trocar llegó por debajo del epiplón. Conclusiones La técnica de ATO es rápida y reproducible . ... (AU)

Introduction The optical trocar access (OTA) is a modified closed technique that aims to minimize the risk of vascular or bowel injuries while reducing the likelihood of gas leakage. A learning curve (LC) effect for OTA has been invoked with n=30 procedures being considered as a threshold to define expertise. We aim to evaluate the impact of the LC within the first thirty cases of OTA performed by a trainee. Methods This is a prospective randomized study on 60 patients elected to laparoscopic gynecological surgery. Patients were randomized to have OTA insertion by a junior surgeon or by an expert. LC was evaluated by: 1) insertion time; number of: 2) corrections by the senior; 3) times the tip of the trocar stopped in the preperitoneal layer; 4) mistakes of skin incision; 5) times the tip of the trocar ends under the omentum; 6) complications. To analyze the LC within the first 30 cases, procedures were stratified in 3 groups (cases 1-10; 11-20; 21-30) for both trainee and expert and LC variables were compared. Results Overall, mean OTA insertion time was 56s. No major intra- and post-operative complications were recorded. Mean insertion time was statistically significantly longer for the trainee compared to the expert within the first 10 cases (91 vs 33s respectively, p=0.01). For cases 11-20 and 21-30, time advantage of the senior surgeon is less evident (p=0.05). The number of times the tip of the trocar stopped in the preperitoneal layer was similar between groups, as well as times the tip of the trocar ends under the omentum. Conclusions OTA is a fast and simple way to achieve the pneumoperitoneum and first trocar insertion as a single step. The current series confirms the effectiveness of the technique since the beginning of the LC. (AU)

Transferencia de habilidades prácticas desde el laboratorio a cirugía in vivo utilizando el sistema robótico Avatera: Estudio experimental / Transfer of acquired practical skills from dry lab into live surgery using the Avatera robotic system: an experimental study

Objetivo Evaluar la transferencia de habilidades adquiridas en el laboratorio a un entorno experimental real para realizar cirugía robótica. Material y métodos Se utilizó un modelo experimental in vivo. Seis residentes y fellows de urología; dos R2 sin exposición previa a cirugía laparoscópica (Grupo 1), dos R4 con exposición intermedia (Grupo 2) y dos fellows formados en cirugía laparoscópica (Grupo 3) realizaron reimplantes ureterales distales, pieloplastia, y nefrectomía radical en tres cerdos hembra. Previamente a realizar los procedimientos, cada participante completó entre 10 y 14 h de formación en cirugía robótica en laboratorio hasta adquirir habilidades para realizar maniobras quirúrgicas básicas (sutura, corte y paso de agujas). Las variables analizadas fueron completar o no con éxito los procedimientos, el tiempo de consola y el tiempo para realizar las maniobras solicitadas y. presencia de complicaciones. Resultados Los tres grupos completaron con éxito todos los procedimientos excepto la pieloplastia, que no la completó el Grupo 1 por sangrado de la vena renal. El Grupo 3 logró un tiempo de consola más corto para todos los procedimientos y para los pasos quirúrgicos por separado, seguido por el Grupo 2. El grupo más lento para completar los procedimientos y los pasos fue el Grupo 1. Conclusiones A pesar de que es necesaria evidencia clínica al respecto, nuestros resultados sugieren que los procedimientos urológicos con asistencia robótica y los pasos más difíciles técnicamente podrían realizarse de manera segura y efectiva después de un entrenamiento adecuado en el laboratorio bajo la supervisión de un mentor. (AU)

Objective To evaluate the transfer of the practical skills of robot-assisted surgery acquired in the dry-lab into a real live experimental setting for performing upper and lower urinary tract surgeries. Material and methods An in vivo experimental study design was utilized. Six urology trainees and fellows; two 2nd year trainees with no previous exposure to laparoscopic surgery (Group 1), two 4th year residents with medium exposure to laparoscopic surgery (Group 2) and two fellows trained to perform laparoscopic surgeries (Group 3) performed ureteral reimplantation into the bladder, pyeloplasty, and radical nephrectomy on three female pigs under general anesthesia. Prior to performing the requested procedures, each participant completed 10-14 hours dry-lab robotic training acquiring skills in basic surgical tasks, such as suturing, cutting and needle passage. The recorded variables were the successful completion of the procedures, the console time, and the time to perform different steps and major complications. Results All procedures were completed successfully by all groups except the pyeloplasty by Group 1 which was complicated by bleeding from the renal vein, and the procedure was abandoned. Group 3 achieved shorter console time for all successfully completed procedures and for separate surgical steps compared to all groups, followed by Group 2. The slowest group for all procedures and steps analyzed was Group 3. Conclusions Although further clinical evidence is needed, the robotic-assisted urological procedures and the most challenging steps could be performed safely and effectively after proper training in the dry lab under mentor supervision according to our study. (AU)

Starting a robotic thoracic surgery program: From wedge resection to sleeve lobectomy in six months. Initial conclusions.

INTRODUCTION: Robot-assisted thoracic surgery (RATS) is a rapidly expanding technique. In our study, we aimed to analyze the results of the process to adopt robotic surgery in our Department of Thoracic Surgery. METHODS: This is an intention-to-treat analysis of a series of consecutive patients operated on using the RATS approach in our hospital from January 2021 to March 2022. Data were registered for patient characteristics, type of surgery, operative times, conversion rate, chest tube duration, length of hospital stay and complications. The IBM SPSS® statistical software was used for the statistical analysis. A cumulative sum analysis of the operating time was performed to define the learning curve. RESULTS: During the study period, 51 patients underwent robotic surgery, including pulmonary and non-pulmonary interventions. In addition, 15 patients (29.4%) underwent non-pulmonary interventions: one pleural (2%), 2 diaphragmatic (3.9%), and 12 mediastinal (23.5%). Among the mediastinal surgeries, one conversion was necessary (8.3%) for a complex vascular malformation, and 11 were completed by RATS, including 7 (58.3%) thymomas, 3 (25%) pleuro-pericardial cysts, and one (8.3%) neurogenic tumor. Mean operative time was 141 min (104-178), mean chest tube duration was 0.9 days (0-2), and mean length of stay was 1.45 days (1-2). Thirty-six patients underwent lung surgery (70.6%). The complete RATS resections (34; 94.4%) included: 3 wedge resections (11.1%), 2 segmentectomies (3.7%), 28 lobectomies (81.5%), and one sleeve lobectomy (3.7%). Mean surgery time was 194.56 min (141-247), chest tube duration was 3.92 days (1-8), and length of stay was 4.6 days (1-8). Complications occurred in 4 patients (11.1%). No 90-day mortalities were registered. CONCLUSIONS: The implementation of RATS was achieved with good clinical results and operative times for all indications. A rapid learning curve was accomplished in short time. Previous VATS experience, patient selection, team training and program continuity are fundamental to successfully develop a RATS program.

Transfer of acquired practical skills from dry lab into live surgery using the avatera robotic system: An experimental study.

OBJECTIVE: To evaluate the transfer of the practical skills of robot-assisted surgery acquired in the dry-lab into a real live experimental setting for performing upper and lower urinary tract surgeries. MATERIAL AND METHODS: An in vivo experimental study design was utilized. Six urology trainees and fellows; two 2nd year trainees with no previous exposure to laparoscopic surgery (Group 1), two 4th year residents with medium exposure to laparoscopic surgery (Group 2) and two fellows trained to perform laparoscopic surgeries (Group 3) performed ureteral reimplantation into the bladder, pyeloplasty, and radical nephrectomy on three female pigs under general anesthesia. Prior to performing the requested procedures, each participant completed 10-14 h dry-lab robotic training acquiring skills in basic surgical tasks, such as suturing, cutting and needle passage. The recorded variables were the successful completion of the procedures, the console time, and the time to perform different steps and major complications. RESULTS: All procedures were completed successfully by all groups except the pyeloplasty by group 1 which was complicated by bleeding from the renal vein, and the procedure was abandoned. Group 3 achieved shorter console time for all successfully completed procedures and for separate surgical steps compared to all groups, followed by Group 2. The slowest group for all procedures and steps analyzed was Group 3. CONCLUSIONS: Although further clinical evidence is needed, the robotic-assisted urological procedures and the most challenging steps could be performed safely and effectively after proper training in the dry lab under mentor supervision according to our study.

Learning curve of optical trocar access during laparoscopic pelvic surgery: A prospective study.

INTRODUCTION: The optical trocar access (OTA) is a modified closed technique that aims to minimize the risk of vascular or bowel injuries while reducing the likelihood of gas leakage. A learning curve (LC) effect for OTA has been invoked with n = 30 procedures being considered as a threshold to define expertise. We aim to evaluate the impact of the LC within the first thirty cases of OTA performed by a trainee. METHODS: This is a prospective randomized study on 60 patients elected to laparoscopic gynecological surgery. Patients were randomized to have OTA insertion by a junior surgeon or by an expert. LC was evaluated by: 1) insertion time; number of: 2) corrections by the senior; 3) times the tip of the trocar stopped in the preperitoneal layer; 4) mistakes of skin incision; 5) times the tip of the trocar ends under the omentum; 6) complications. To analyze the LC within the first 30 cases, procedures were stratified in 3 groups (cases 1-10; 11-20; 21-30) for both trainee and expert and LC variables were compared. RESULTS: Overall, mean OTA insertion time was 56 s. No major intra- and post-operative complications were recorded. Mean insertion time was statistically significantly longer for the trainee compared to the expert within the first 10 cases (91 vs 33 s respectively, P = .01). For cases 11-20 and 21-30, time advantage of the senior surgeon is less evident (P = .05). The number of times the tip of the trocar stopped in the preperitoneal layer was similar between groups, as well as times the tip of the trocar ends under the omentum. CONCLUSIONS: OTA is a fast and simple way to achieve the pneumoperitoneum and first trocar insertion as a single step. The current series confirms the effectiveness of the technique since the beginning of the LC.

Tiroidectomía endoscópica transoral por vía vestibular: resultados de los 53 primeros casos / Transoral endoscopic thyroidectomy vestibular approach: Results after 53 first cases

Introducción: La tiroidectomía endoscópica transoral por vía vestibular permite el acceso al tiroides sin cicatrices visibles y con el mejor resultado cosmético posible. Métodos: Estudio observacional prospectivo de 53 pacientes sometidos a tiroidectomía endoscópica transoral desde julio de 2017 hasta junio de 2021. Resultados: Cincuenta y dos casos (98,1%) fueron mujeres con una mediana de edad de 44 años. El nódulo tiroideo fue la indicación quirúrgica más frecuente (73,6%). Se realizaron 42 lobectomías,11 tiroidectomías totales y en 4 casos se asoció vaciamiento ganglionar del compartimento central izquierdo. La mediana de tiempo para la colocación de trócares fue de 14min, y para la lobectomía, la tiroidectomía total y el vaciamiento ganglionar del compartimento central izquierdo, de 80, 140 y 30min, respectivamente. La mediana de estancia hospitalaria fue de 2 días. Cuatro pacientes presentaron disfonía (7,5%), pero la laringoscopia solo confirmó lesión del recurrente en 2 casos, una de ellas permanente (1,6%). En los pacientes con tiroidectomía total la frecuencia de hipoparatiroidismo transitorio fue del 18,2% y el permanente de 0%. Dentro de las complicaciones asociadas al abordaje, en todos los pacientes se presentó anestesia de la región mentoniana transitoria y de intensidad variable. Conclusiones: La cirugía transoral es un abordaje de aplicación reciente en nuestra unidad. Los resultados en nuestros primeros pacientes muestran que es un abordaje eficaz y seguro cuando se realiza en pacientes bien seleccionados, con el mejor resultado cosmético y con complicaciones nuevas, asociadas al abordaje, transitorias en nuestra serie. (AU)

Introduction: Transoral endoscopic thyroidectomy through vestibular approach allows access to the thyroid with the best cosmetic results as there are no visible scars. Methods: Here we present a prospective observational study of 53 patients which underwent transoral endoscopic thyroidectomy from July 2017 to June 2021. Results: Fifty-two cases (98.1%) were women (median age 44 years old). Thyroid nodule was the main surgical indication accounting 73.6% of cases. We performed 42 lobectomies and 11 total thyroidectomies; 4 left central neck dissection were also associated. The median surgical time for port placement was 14min, and for lobectomy, total thyroidectomy and left central neck dissection were 80, 140 and 30min, respectively. The median of hospital stay was 2 days. Dysphonia was present in 4 patients (7.5%); however, laryngoscopy only confirmed laryngeal nerve impairment in 2 cases, one of them classified as permanent (1.6%). In those patients that underwent total thyroidectomy, the rate of transient hypoparathyroidism was 18.2% whereas permanent was 0%. Regarding complications associated to the new approach, transient chin numbness appeared in all patients with a variable degree of intensity. Conclusions: Transoral surgery is a recent approach in our unit. Our results, based on the first 53 patients, show that it is a safe and effective approach when performed in appropriately selected patients offering the best cosmetic result. Besides, new complications associated to the approach has been shown to be transient. (AU)

Tiroidectomía endoscópica transoral por vía vestibular: resultados de los 53 primeros casos / Transoral endoscopic thyroidectomy vestibular approach: Results after 53 first cases

Introducción: La tiroidectomía endoscópica transoral por vía vestibular permite el acceso al tiroides sin cicatrices visibles y con el mejor resultado cosmético posible. Métodos: Estudio observacional prospectivo de 53 pacientes sometidos a tiroidectomía endoscópica transoral desde julio de 2017 hasta junio de 2021. Resultados: Cincuenta y dos casos (98,1%) fueron mujeres con una mediana de edad de 44 años. El nódulo tiroideo fue la indicación quirúrgica más frecuente (73,6%). Se realizaron 42 lobectomías,11 tiroidectomías totales y en 4 casos se asoció vaciamiento ganglionar del compartimento central izquierdo. La mediana de tiempo para la colocación de trócares fue de 14min, y para la lobectomía, la tiroidectomía total y el vaciamiento ganglionar del compartimento central izquierdo, de 80, 140 y 30min, respectivamente. La mediana de estancia hospitalaria fue de 2 días. Cuatro pacientes presentaron disfonía (7,5%), pero la laringoscopia solo confirmó lesión del recurrente en 2 casos, una de ellas permanente (1,6%). En los pacientes con tiroidectomía total la frecuencia de hipoparatiroidismo transitorio fue del 18,2% y el permanente de 0%. Dentro de las complicaciones asociadas al abordaje, en todos los pacientes se presentó anestesia de la región mentoniana transitoria y de intensidad variable. Conclusiones: La cirugía transoral es un abordaje de aplicación reciente en nuestra unidad. Los resultados en nuestros primeros pacientes muestran que es un abordaje eficaz y seguro cuando se realiza en pacientes bien seleccionados, con el mejor resultado cosmético y con complicaciones nuevas, asociadas al abordaje, transitorias en nuestra serie. (AU)

Introduction: Transoral endoscopic thyroidectomy through vestibular approach allows access to the thyroid with the best cosmetic results as there are no visible scars. Methods: Here we present a prospective observational study of 53 patients which underwent transoral endoscopic thyroidectomy from July 2017 to June 2021. Results: Fifty-two cases (98.1%) were women (median age 44 years old). Thyroid nodule was the main surgical indication accounting 73.6% of cases. We performed 42 lobectomies and 11 total thyroidectomies; 4 left central neck dissection were also associated. The median surgical time for port placement was 14min, and for lobectomy, total thyroidectomy and left central neck dissection were 80, 140 and 30min, respectively. The median of hospital stay was 2 days. Dysphonia was present in 4 patients (7.5%); however, laryngoscopy only confirmed laryngeal nerve impairment in 2 cases, one of them classified as permanent (1.6%). In those patients that underwent total thyroidectomy, the rate of transient hypoparathyroidism was 18.2% whereas permanent was 0%. Regarding complications associated to the new approach, transient chin numbness appeared in all patients with a variable degree of intensity. Conclusions: Transoral surgery is a recent approach in our unit. Our results, based on the first 53 patients, show that it is a safe and effective approach when performed in appropriately selected patients offering the best cosmetic result. Besides, new complications associated to the approach has been shown to be transient. (AU)

Transoral endoscopic thyroidectomy vestibular approach: Results after 53 first cases.

INTRODUCTION: Trans Oral Endoscopic Thyroidectomy through Vestibular Approach (TOETVA) allows access to the thyroid with the best cosmetic results as there are no visible scars. METHODS: Here we present a prospective observational study of 53 patients which underwent TOETVA from July 2017 to June 2021. RESULTS: Fifty-two cases (98.1%) cases were women (median age 44 years old). Thyroid nodule was the main surgical indication accounting 73.6% of cases. We performed 42 lobectomies and 11 total thyroidectomies; 4 left Central Neck Dissection (CND) were also associated. The median surgical time for port placement was 14 min and for lobectomy, total thyroidectomy and left CND were 80, 140 and 30 min, respectively. The median of hospital stay was 2 days. Dysphonia was present in 4 patients; however, laryngoscopy only confirmed laryngeal nerve impairment in 2 cases, one of them classified as permanent (1.6%). In those patients that underwent total thyroidectomy, the rate of transient hypoparathyroidism was 18.2% whereas permanent was 0%. Regarding complications associated to the new approach, transient chin numbness appeared in all patients with a variable degree of intensity. CONCLUSTIONS: Transoral surgery is a recent approach in our Unit. Our results, based on the first 53 patients, show that it is a safe and effective approach when performed in appropriately selected patients offering the best cosmetic result. Besides, new complications associated to the approach has been shown to be transient.

Análisis del impacto de la curva de aprendizaje de la cistectomía radical asistida por robot con derivación urinaria intracorpórea sobre los resultados perioperatorios / Evaluating the impact of the learning curve on the perioperative outcomes of robot-assisted radical cystectomy with intracorporeal urinary diversion

Introducción La cistectomía radical asistida por robot (CRAR) con derivación urinaria intracorpórea (DUIC) es un procedimiento técnicamente complejo. Nuestro objetivo fue analizar el impacto de la curva de aprendizaje (CA) de la CRAR con DUIC sobre los resultados perioperatorios y patológicos.Material y métodos Estudio retrospectivo de 62 pacientes consecutivos intervenidos mediante CRAR con DUIC por tumor vesical entre 2015 y 2020. Se compararon 3 grupos consecutivos de 20 (G1), 20 (G2) y 22 (G3) pacientes para analizar el impacto de la CA. Los casos de G1 fueron intervenidos por un cirujano sénior con experiencia en cirugía robótica y los de G2-G3 por 2cirujanos júnior sin experiencia, pero tutorizados por el sénior.Resultados Los 3grupos tenían características clínico-patológicas similares. A 15 pacientes (24%) se les realizó una neovejiga y a 47 (75%) un conducto ileal. El tiempo medio operatorio descendió 60 min entre G1 y G3 (p=0,001). Ningún paciente precisó conversión a cirugía abierta ni tuvo complicaciones intraoperatorias. No se objetivaron diferencias en la tasa de márgenes positivos (p=0,6) ni en el número de ganglios extraídos (p=0,061) entre los grupos. La tasa de complicaciones postoperatorias fue del 77% y no varió durante la CA (p=0,49). Se objetivó una tendencia en la reducción de tasa de estenosis ureteroileal del 25% en G1 al 9% en G3 (p=0,217).Conclusiones La incorporación de cirujanos júnior a un programa de CRAR con DUIC a partir de los 20 primeros casos no compromete los resultados perioperatorios ni patológicos. Durante la CA se podría reducir el tiempo operatorio y la tasa de estenosis ureteroileal (AU)

Introduction Robot-assisted radical cystectomy (RARC) with intracorporeal urinary diversion (ICUD) is a technically difficult procedure. Our aim was to evaluate the potential impact of the learning curve (LC) on perioperative and pathological outcomes of RARC with ICUD.Material and methods Retrospective study of 62 consecutive patients who underwent RARC with ICUD for bladder cancer between 2015-2020. We compared 3 consecutive groups of 20 (G1), 20 (G2), and 22 (G3) patients to analyze the impact of the LC. G1 cases were performed by a senior surgeon experienced in robotic surgery, while G2-G3 were performed by 2 junior surgeons without experience under the mentorship of the senior surgeon.Results The 3 groups had similar clinical and pathological characteristics. A total of 15 patients (24%) received a neobladder and 47 (75%) an ileal conduit. The mean operative time decreased 60minutes between G1-G3 (P=0.001). No conversions to open approach or intraoperative complications were reported. There were no differences between groups regarding positive margin rates (P=0.6) or the number of lymph nodes removed (P=0.061). The postoperative complication rate was 77% and did not change during the LC (P=0.49). Uretero-enteric stricture rate decreased from 25% in G1 to 9% in G3 (P=0.217).Conclusions The inclusion of júnior surgeons to a RARC with ICUD program after the initial 20 cases does not have an impact on the perioperative and pathological outcomes of the procedure. The operative time and the uretero-enteric stricture rate could be reduced during the LC (AU)

Scapular notching in reverse shoulder arthroplasty. Relationship with surgeon's experience and clinical outcomes / Notching escapular en las prótesis invertidas de hombro. Su relación con la experiencia del cirujano y con los resultados clínicos

Background: Scapular Notching is a problem frequently seen in Reverse shoulder arthroplasties (RSAs), produced by a collision between the humeral component and the scapula. The main objective of this study is to analyze whether this problem decreases with the surgeons experience. As secondary objectives, assessing whether there is a relationship between its appearance and the clinical and functional outcome of patients. Methods: We retrospectively reviewed 101 patients with 105 RSAs; we analyzed complications, focusing on scapular notching. Main follow-up time was 36 month (12-72). The clinical and functional outcomes were evaluated with the Constant scale and the QuickDash questionnaire. Results: Forty-two patients (40%) had some degree of scapular notching. Of these, 25 patients had grade I, 14 had grade II and 3 had grade III notching. The average postoperative Constant score for the entire series was 60.72. A tendency toward a reduced incidence of notching was observed with increasing numbers of operated cases and experience of the surgeon (p=0.04). In the group of patients who had notching, the average postoperative Constant score was 56, and in the group that developed notching, the average score was 63. Patients with notching had significantly lower pain scores (p=0.012). Conclusions: Scapular notching is a common problem of RSA. In RSA, the experience of the surgeon reduces the appearance of problems and complications. Scapular notching is related to poorer clinical outcomes with respect to pain.(AU)

Introducción: La erosión o muesca escapular (notching escapular) es un problema que se observa con frecuencia en las prótesis invertidas de hombro, producido por un choque entre el componente humeral y el cuello de la escápula. El objetivo principal de nuestro trabajo es analizar si disminuye el notching escapular con el aumento de la experiencia del cirujano. Como objetivos secundarios, el valorar si existe una relación entre su aparición y el resultado funcional y clínico en los pacientes. Material y método: Se realiza una revisión retrospectiva de 101 pacientes con 105 prótesis invertidas de hombro, valorando radiográficamente la aparición de notching escapular. El tiempo medio de seguimiento fue de 36 meses (rango, 12-72). Se objetivan los resultados clínico-funcionales con la escala Constant y el cuestionario QuickDash. Resultados: Cuarenta y dos pacientes (40%) presentaron algún grado de notching escapular. De ellos, 25 pacientes tenían un grado I, 14 un grado II y tres un grado III. El Constant postoperatorio medio para toda la serie fue de 60,72. Se observó una tendencia a disminuir la incidencia de notching conforme aumentaba el número de casos intervenidos y la experiencia del cirujano (p = 0,04). En el grupo de los pacientes que presentaban notching escapular, el Constant postoperatorio fue de 56 y en el grupo que no desarrolló notching fue del 63. Los pacientes con notching presentaban puntuaciones inferiores en cuanto al dolor siendo la diferencia estadísticamente significativa (p = 0,012). Conclusiones: El notching escapular es un problema frecuente en las prótesis invertidas de hombro, en las cuales la curva de aprendizaje influye positivamente en la diminución de su aparición. La aparición de notching escapular está relacionado con peores resultados clínicos en cuanto al dolor se refiere.(AU)

Notching escapular en las prótesis invertidas de hombro. Su relación con la experiencia del cirujano y con los resultados clínicos / Scapular notching in reverse shoulder arthroplasty. Relationship with surgeons experience and clinical outcomes

Introducción: La erosión o muesca escapular (notching escapular) es un problema que se observa con frecuencia en las prótesis invertidas de hombro, producido por un choque entre el componente humeral y el cuello de la escápula. El objetivo principal de nuestro trabajo es analizar si disminuye el notching escapular con el aumento de la experiencia del cirujano. Como objetivos secundarios, el valorar si existe una relación entre su aparición y el resultado funcional y clínico en los pacientes. Material y métodos: Se realiza una revisión retrospectiva de 101 pacientes con 105 prótesis invertidas de hombro, valorando radiográficamente la aparición de notching escapular. El tiempo medio de seguimiento fue de 36 meses (rango, 12-72). Se objetivan los resultados clínico-funcionales con la escala Constant y el cuestionario QuickDash. Resultados: Cuarenta y dos pacientes (40%) presentaron algún grado de notching escapular. De ellos, 25 pacientes tenían un grado I, 14 un grado II y tres un grado III. El Constant postoperatorio medio para toda la serie fue de 60,72. Se observó una tendencia a disminuir la incidencia de notching conforme aumentaba el número de casos intervenidos y la experiencia del cirujano (p = 0,04). En el grupo de los pacientes que presentaban notching escapular, el Constant postoperatorio fue de 56 y en el grupo que no desarrolló notching fue del 63. Los pacientes con notching presentaban puntuaciones inferiores en cuanto al dolor siendo la diferencia estadísticamente significativa (p = 0,012). Conclusiones: El notching escapular es un problema frecuente en las prótesis invertidas de hombro, en las cuales la curva de aprendizaje influye positivamente en la diminución de su aparición. La aparición de notching escapular está relacionado con peores resultados clínicos en cuanto al dolor se refiere.(AU)

Background: Scapular Notching is a problem frequently seen in Reverse shoulder arthroplasties (RSAs), produced by a collision between the humeral component and the scapula. The main objective of this study is to analyze whether this problem decreases with the surgeons experience. As secondary objectives, assessing whether there is a relationship between its appearance and the clinical and functional outcome of patients. Methods: We retrospectively reviewed 101 patients with 105 RSAs; we analyzed complications, focusing on scapular notching. Main follow-up time was 36 month (12-72). The clinical and functional outcomes were evaluated with the Constant scale and the QuickDash questionnaire. Results: Forty-two patients (40%) had some degree of scapular notching. Of these, 25 patients had grade I, 14 had grade II and 3 had grade III notching. The average postoperative Constant score for the entire series was 60.72. A tendency toward a reduced incidence of notching was observed with increasing numbers of operated cases and experience of the surgeon (p=0.04). In the group of patients who had notching, the average postoperative Constant score was 56, and in the group that developed notching, the average score was 63. Patients with notching had significantly lower pain scores (p=0.012). Conclusions: Scapular notching is a common problem of RSA. In RSA, the experience of the surgeon reduces the appearance of problems and complications. Scapular notching is related to poorer clinical outcomes with respect to pain.(AU)

Evaluation of the learning curve and initial outcomes with a short cervicometaphyseal fixation stem: A case series / Evaluación de la curva de aprendizaje y resultados iniciales con un vástago corto de fijación cervicometafisaria: Una serie de casos

Introduction: Total hip arthroplasty in young patients has evolved in recent decades, and the use of short stems in young adult patients has been gaining popularity. The restitution of the biomechanics of the hip is a primary requirement to determine the future success of total hip replacement, and even more so in young adults who present the particularity of having a high functional demand and a long life expectancy. Objective: The aim of this prospective study was to evaluate the learning curve and initial clinical–radiological outcomes of the Alteon Neck Preserving Stem™ (ANPS) (Exactech, Gainesville, FL, USA) with a minimum of 2 years follow up. Material and methods: We conducted a multicenter prospective study that analyzed 90 consecutive total hip replacements during 2014. We performed a clinical–radiological analysis measuring Harris Hip Score (HHS), subjective Rodes and Maudsley satisfaction evaluation, radiolucencies, components position, limb length discrepancy, heterotopic ossification, medical and surgical complications and learning curve. Results: During the first 30 cases, the intraoperative complication rate was 16%, while in the next 60 cases no intraoperative complications were reported. Thigh pain was reported in 3 cases (3.3%), being 2 moderates, and 1 severe. In 2 cases subsidences of 3 mm were detected in the first scheduled X-ray, both related to intraoperative fractures with no progression after 3 months. Mean HHS improved from 42.9 points (range 37–54 points) preoperatively to 93.2 on average (range, 87–96) at the end of the follow up (p < 0.01). Subjective evaluation was excellent in 75 (83.3%) cases and good in 15 patients (16.6%). Conclusions: This short stem has good clinical radiological results in a short and medium term follow-up and in the hands of surgeons specializing in arthroplasty the learning curve is estimated to be less than 30 surgeries.(AU)

Introducción: La artroplastia total de cadera en pacientes jóvenes ha ido evolucionando en las últimas décadas y la utilización de tallos cortos en pacientes adultos jóvenes ha ganado popularidad. La restitución de la biomecánica de la cadera es requisito primordial para determinar el éxito a futuro del reemplazo total de cadera, y aún más en los adultos jóvenes quienes presentan la particularidad de tener una alta demanda funcional y una esperanza de vida prolongada. Objetivo: El objetivo de este estudio prospectivo fue evaluar la curva de aprendizaje y los resultados clínico-radiológicos iniciales del Alteon Neck Preserving Stem™ (ANPS) (Exactech, Gainesville, FL, EE. UU.) con un mínimo de dos años de seguimiento. Material y métodos: Se realizó un estudio prospectivo multicéntrico que analizó 90 reemplazos totales consecutivos de cadera durante 2014. Realizamos un análisis clínico-radiológico utilizando Harris Hip Score (HHS), evaluación de satisfacción subjetiva de Roles y Maudsley, radiolucencias, posición de los componentes, discrepancia en la longitud de las extremidades, osificación heterotópica, complicaciones médicas y quirúrgicas y un análisis de la curva de aprendizaje. Resultados: Durante los primeros 30 casos la tasa de complicaciones intraoperatorias fue del 16% mientras que en los siguientes 60 casos no se reportó ninguna complicación intraquirúrgica. El dolor de muslo se notificó en tres casos (3,3%), siendo dos moderados y uno grave. En dos casos se detectaron hundimientos de 3 mm en la primera radiografía programada, ambas relacionadas con fracturas intraoperatorias sin progresión después de tres meses. La media de HHS mejoró de 42,9 puntos (rango 37 a 54 puntos) preoperatoriamente a 93,2 en promedio (rango, 87-96) al final del seguimiento (p < 0,01). La evaluación subjetiva fue excelente en 75 casos (83,3%) y buena en 15 casos (16,6%).(AU)

Evaluación de la curva de aprendizaje y resultados iniciales con un vástago corto de fijación cervicometafisaria: Una serie de casos / Evaluation of the learning curve and initial outcomes with a short cervicometaphyseal fixation stem: A case series

Introducción: La artroplastia total de cadera en pacientes jóvenes ha ido evolucionando en las últimas décadas y la utilización de tallos cortos en pacientes adultos jóvenes ha ganado popularidad. La restitución de la biomecánica de la cadera es requisito primordial para determinar el éxito a futuro del reemplazo total de cadera, y aún más en los adultos jóvenes quienes presentan la particularidad de tener una alta demanda funcional y una esperanza de vida prolongada. Objetivo: El objetivo de este estudio prospectivo fue evaluar la curva de aprendizaje y los resultados clínico-radiológicos iniciales del Alteon Neck Preserving Stem™ (ANPS) (Exactech, Gainesville, FL, EE. UU.) con un mínimo de dos años de seguimiento. Material y métodos: Se realizó un estudio prospectivo multicéntrico que analizó 90 reemplazos totales consecutivos de cadera durante 2014. Realizamos un análisis clínico-radiológico utilizando Harris Hip Score (HHS), evaluación de satisfacción subjetiva de Roles y Maudsley, radiolucencias, posición de los componentes, discrepancia en la longitud de las extremidades, osificación heterotópica, complicaciones médicas y quirúrgicas y un análisis de la curva de aprendizaje. Resultados: Durante los primeros 30 casos la tasa de complicaciones intraoperatorias fue del 16% mientras que en los siguientes 60 casos no se reportó ninguna complicación intraquirúrgica. El dolor de muslo se notificó en tres casos (3,3%), siendo dos moderados y uno grave. En dos casos se detectaron hundimientos de 3 mm en la primera radiografía programada, ambas relacionadas con fracturas intraoperatorias sin progresión después de tres meses. La media de HHS mejoró de 42,9 puntos (rango 37 a 54 puntos) preoperatoriamente a 93,2 en promedio (rango, 87-96) al final del seguimiento (p < 0,01). La evaluación subjetiva fue excelente en 75 casos (83,3%) y buena en 15 casos (16,6%).(AU)

Introduction: Total hip arthroplasty in young patients has evolved in recent decades, and the use of short stems in young adult patients has been gaining popularity. The restitution of the biomechanics of the hip is a primary requirement to determine the future success of total hip replacement, and even more so in young adults who present the particularity of having a high functional demand and a long life expectancy. Objective: The aim of this prospective study was to evaluate the learning curve and initial clinical–radiological outcomes of the Alteon Neck Preserving Stem™ (ANPS) (Exactech, Gainesville, FL, USA) with a minimum of 2 years follow up. Material and methods: We conducted a multicenter prospective study that analyzed 90 consecutive total hip replacements during 2014. We performed a clinical–radiological analysis measuring Harris Hip Score (HHS), subjective Rodes and Maudsley satisfaction evaluation, radiolucencies, components position, limb length discrepancy, heterotopic ossification, medical and surgical complications and learning curve. Results: During the first 30 cases, the intraoperative complication rate was 16%, while in the next 60 cases no intraoperative complications were reported. Thigh pain was reported in 3 cases (3.3%), being 2 moderates, and 1 severe. In 2 cases subsidences of 3 mm were detected in the first scheduled X-ray, both related to intraoperative fractures with no progression after 3 months. Mean HHS improved from 42.9 points (range 37–54 points) preoperatively to 93.2 on average (range, 87–96) at the end of the follow up (p < 0.01). Subjective evaluation was excellent in 75 (83.3%) cases and good in 15 patients (16.6%). Conclusions: This short stem has good clinical radiological results in a short and medium term follow-up and in the hands of surgeons specializing in arthroplasty the learning curve is estimated to be less than 30 surgeries.(AU)

Evaluation of the learning curve and initial outcomes with a short cervicometaphyseal fixation stem: A case series. / Evaluación de la curva de aprendizaje y resultados iniciales con un vástago corto de fijación cervicometafisaria: Una serie de casos.

INTRODUCTION: Total hip arthroplasty in young patients has evolved in recent decades, and the use of short stems in young adult patients has been gaining popularity. The restitution of the biomechanics of the hip is a primary requirement to determine the future success of total hip replacement, and even more so in young adults who present the particularity of having a high functional demand and a long life expectancy. OBJECTIVE: The aim of this prospective study was to evaluate the learning curve and initial clinical-radiological outcomes of the Alteon Neck Preserving Stem™ (ANPS) (Exactech, Gainesville, FL, USA) with a minimum of 2 years follow up. MATERIAL AND METHODS: We conducted a multicenter prospective study that analyzed 90 consecutive total hip replacements during 2014. We performed a clinical-radiological analysis measuring Harris Hip Score (HHS), subjective Rodes and Maudsley satisfaction evaluation, radiolucencies, components position, limb length discrepancy, heterotopic ossification, medical and surgical complications and learning curve. RESULTS: During the first 30 cases, the intraoperative complication rate was 16%, while in the next 60 cases no intraoperative complications were reported. Thigh pain was reported in 3 cases (3.3%), being 2 moderates, and 1 severe. In 2 cases subsidences of 3 mm were detected in the first scheduled X-ray, both related to intraoperative fractures with no progression after 3 months. Mean HHS improved from 42.9 points (range 37-54 points) preoperatively to 93.2 on average (range, 87-96) at the end of the follow up (p < 0.01). Subjective evaluation was excellent in 75 (83.3%) cases and good in 15 patients (16.6%). CONCLUSIONS: This short stem has good clinical radiological results in a short and medium term follow-up and in the hands of surgeons specializing in arthroplasty the learning curve is estimated to be less than 30 surgeries.

Scapular notching in reverse shoulder arthroplasty. Relationship with surgeon̈s experience and clinical outcomes. / Notching escapular en las prótesis invertidas de hombro. Su relación con la experiencia del cirujano y con los resultados clínicos.

BACKGROUND: Scapular Notching is a problem frequently seen in Reverse shoulder arthroplasties (RSAs), produced by a collision between the humeral component and the scapula. The main objective of this study is to analyze whether this problem decreases with the surgeons experience. As secondary objectives, assessing whether there is a relationship between its appearance and the clinical and functional outcome of patients. METHODS: We retrospectively reviewed 101 patients with 105 RSAs; we analyzed complications, focusing on scapular notching. Main follow-up time was 36 month (12-72). The clinical and functional outcomes were evaluated with the Constant scale and the QuickDash questionnaire. RESULTS: Forty-two patients (40%) had some degree of scapular notching. Of these, 25 patients had grade I, 14 had grade II and 3 had grade III notching. The average postoperative Constant score for the entire series was 60.72. A tendency toward a reduced incidence of notching was observed with increasing numbers of operated cases and experience of the surgeon (p=0.04). In the group of patients who had notching, the average postoperative Constant score was 56, and in the group that developed notching, the average score was 63. Patients with notching had significantly lower pain scores (p=0.012). CONCLUSIONS: Scapular notching is a common problem of RSA. In RSA, the experience of the surgeon reduces the appearance of problems and complications. Scapular notching is related to poorer clinical outcomes with respect to pain.

Evaluating the impact of the learning curve on the perioperative outcomes of robot-assisted radical cystectomy with intracorporeal urinary diversion.

INTRODUCTION: Robot-assisted radical cystectomy (RARC) with intracorporeal urinary diversion (ICUD) is a technically difficult procedure. Our aim was to evaluate the potential impact of the learning curve (LC) on perioperative and pathological outcomes of RARC with ICUD. MATERIAL AND METHODS: Retrospective study of 62 consecutive patients who underwent RARC with ICUD for bladder cancer between 2015-2020. We compared 3 consecutive groups of 20 (G1), 20 (G2), and 22 (G3) patients to analyze the impact of the LC. G1 cases were performed by a senior surgeon experienced in robotic surgery, while G2-G3 were performed by 2 junior surgeons without experience under the mentorship of the senior surgeon. RESULTS: The 3 groups had similar clinical and pathological characteristics. A total of 15 patients (24%) received a neobladder and 47 (75%) an ileal conduit. The mean operative time decreased 60 min between G1-G3 (p = 0.001). No conversions to open approach or intraoperative complications were reported. There were no differences between groups regarding positive margin rates (p = 0.6) or the number of lymph nodes removed (p = 0.061). The postoperative complication rate was 77% and did not change during the LC (p = 0.49). Uretero-enteric stricture rate decreased from 25% in G1 to 9% in G3 (p = 0.217). CONCLUSIONS: The inclusion of junior surgeons to a RARC with ICUD program after the initial 20 cases does not have an impact on the perioperative and pathological outcomes of the procedure. The operative time and the uretero-enteric stricture rate could be reduced during the LC.

Evaluating the impact of the learning curve on the perioperative outcomes of robot-assisted radical cystectomy with intracorporeal urinary diversion. / Análisis del impacto de la curva de aprendizaje de la cistectomía radical asistida por robot con derivación urinaria intracorpórea sobre los resultados perioperatorios.

INTRODUCTION: Robot-assisted radical cystectomy (RARC) with intracorporeal urinary diversion (ICUD) is a technically difficult procedure. Our aim was to evaluate the potential impact of the learning curve (LC) on perioperative and pathological outcomes of RARC with ICUD. MATERIAL AND METHODS: Retrospective study of 62 consecutive patients who underwent RARC with ICUD for bladder cancer between 2015-2020. We compared 3 consecutive groups of 20 (G1), 20 (G2), and 22 (G3) patients to analyze the impact of the LC. G1 cases were performed by a senior surgeon experienced in robotic surgery, while G2-G3 were performed by 2 junior surgeons without experience under the mentorship of the senior surgeon. RESULTS: The 3 groups had similar clinical and pathological characteristics. A total of 15 patients (24%) received a neobladder and 47 (75%) an ileal conduit. The mean operative time decreased 60minutes between G1-G3 (P=0.001). No conversions to open approach or intraoperative complications were reported. There were no differences between groups regarding positive margin rates (P=0.6) or the number of lymph nodes removed (P=0.061). The postoperative complication rate was 77% and did not change during the LC (P=0.49). Uretero-enteric stricture rate decreased from 25% in G1 to 9% in G3 (P=0.217). CONCLUSIONS: The inclusion of júnior surgeons to a RARC with ICUD program after the initial 20 cases does not have an impact on the perioperative and pathological outcomes of the procedure. The operative time and the uretero-enteric stricture rate could be reduced during the LC.