title: Impact of a single-surgeon learning curve on complications, positioning injuries, and renal function in patients undergoing robot-assisted radical prostatectomy and extended pelvic lymph node dissection.
abstract: OBJECTIVE
  To assess the impact of a single-surgeon learning curve on complications, positioning injuries, and renal function in patients undergoing robot-assisted radical prostatectomy and extended pelvic lymph node dissection for intermediate- or high-risk clinically localized prostate cancer.
  
  
  METHODS
  From November 2008 to October 2012, a total of 233 consecutive patients were treated by a single surgeon experienced in open and laparoscopic procedures. Four subgroups of patients (1: cases 1-59; 2: 60-117; 3: 118-175; and 4: 176-233) were compared. Complications were classified according to the modified Clavien system. Serum creatine kinase, as an indicator of tissue injury, was measured before, during, and for 5 days after surgery. Renal function monitoring was started preoperatively and ended at discharge. Minimum follow-up was 3 months. Variables were compared using chi-square and Wilcoxon tests.
  
  
  RESULTS
  Overall, 115 complications were reported in 98 of 233 patients (42%) and significantly decreased after 175 procedures (P = .028). Minor complications (Clavien grades 1-2) represented the most frequent events (86 of 115 [75%]), with a significant drop in group 4 (P <.01). Similarly, the rate of positioning injuries (groups 1-4: 31%, 29%, 29%, and 7%, respectively) showed a significant improvement in group 4 (P = .023). Creatine kinase levels significantly decreased with increased experience (group 1 vs groups 2-4: P <.01). Renal function was unaltered postoperatively.
  
  
  CONCLUSIONS
  A surgeon with extensive open and laparoscopic experience presents a safe learning curve in regard to robot-assisted radical prostatectomy and extended pelvic lymph node dissection. With increasing experience, the rates of overall and positioning-related complications significantly decrease after 175 procedures. No detrimental effect on renal function is to be expected.
authors.affiliation: Klinik für Urologie, Luzerner Kantosspital, Lucerne, Switzerland; Department of Obstetrics, Gynecology and Urology, 'Sapienza' University, Rome, Italy.
authors.forename: Giovanni Battista
authors.initials: GB
authors.lastname: Di Pierro
authors.affiliation: Service d'Urologie, HUG et Faculté de Médecine, Geneva, Switzerland.
authors.forename: Johann Gregory
authors.initials: JG
authors.lastname: Wirth
authors.affiliation: Klinik für Urologie, Luzerner Kantosspital, Lucerne, Switzerland.
authors.forename: Matteo
authors.initials: M
authors.lastname: Ferrari
authors.affiliation: Klinik für Urologie, Luzerner Kantosspital, Lucerne, Switzerland.
authors.forename: Hansjörg
authors.initials: H
authors.lastname: Danuser
authors.affiliation: Klinik für Urologie, Luzerner Kantosspital, Lucerne, Switzerland. Electronic address: agomat@gmx.ch.
authors.forename: Agostino
authors.initials: A
authors.lastname: Mattei
mesh_terms: D000368:Aged; D003402:Creatine Kinase / Q000097:blood; D006801:Humans; D007431:Intraoperative Complications; D007668:Kidney / Q000502:physiology; D059032:Learning Curve; D008197:Lymph Node Excision / Q000379:methods*; D008198:Lymph Nodes / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D019060:Minimally Invasive Surgical Procedures / Q000379:methods; D056888:Patient Positioning; D011183:Postoperative Complications; D011446:Prospective Studies; D011467:Prostate / Q000601:surgery; D011468:Prostatectomy / Q000379:methods*; D011471:Prostatic Neoplasms / Q000473:pathology / Q000601:surgery*; D012044:Regression Analysis; D065287:Robotic Surgical Procedures; D016896:Treatment Outcome
chemical_list: D003402:Creatine Kinase