Our study objective was to evaluate the benefit of the proctor environment on the learning curve associated with robotic-assisted laparoscopic pyeloplasty (RALP) in a pediatric population.
All pediatric RALPs performed at our institution between 2005 and 2011 were included. Procedures were performed by three surgeons: CAP (expert), STC (trainee to expert) and CAH (trainee). Both training surgeons were experienced laparoscopic surgeons. A proctor environment was established necessitating 3-5 proctored cases before a surgeon was able to perform cases on his own. Additional cases were required if proctor or training surgeon felt more cases were needed to establish competency. Variables analyzed included stent placement (antegrade or retrograde), da Vinci® robotic surgical system type (Standard or Si), chief or junior resident assistance, complications, concurrent procedures, and improvement in operating (OR) times. Bilateral and redo surgeries were excluded from OR time analysis which was defined as time in to time out of operating room. Time trend analysis was performed using linear regression.
A total of 111 RALPs were performed during the time period. Median age at intervention was 36 months (range 3 mos – 20 yrs). Most patients (87%) underwent retrograde stent placement. The majority of cases (80%) were performed using the da Vinci® Standard surgical system. In 74% (82) of cases, the chief resident assisted with the procedure. A minority (13%) of patients required concurrent procedures. Almost all patients (90%) were discharged within 48 hours. Overall mean operative time was 3:25 hours (SD ± 42 min). As expected, OR time trend analysis showed no significant improvement over time for the expert surgeon, however significant improvement was seen in the trainee to expert surgeon (p < .05). One surgeon's sample size (trainee) was limited so no meaningful analysis could be performed.
The transition from laparoscopic pyeloplasty to RALP in a proctor environment results in a negligible learning curve with high success and minimal complications. The dual module da Vinci® Si surgical system expedites this process further with the operative surgeon acting as a true “co-pilot”.