title: The learning curve and factors affecting warm ischemia time during robot-assisted partial nephrectomy.
abstract: BACKGROUND
  The learning curve for robotic partial nephrectomy was investigated for an experienced laparoscopic surgeon and factors associated with warm ischemia time (WIT) were assessed.
  
  
  METHODS
  Between 2007 and 2014, one surgeon completed 171 procedures. Operative time, blood loss, complications and ischemia time were examined to determine the learning curve. The learning curve was defined as the number of procedures needed to reach the targeted goal for WIT, which most recently was 20 min. Statistical analyses including multivariable regression analysis and matching were performed.
  
  
  RESULTS
  Comparing the first 30 to the last 30 patients, mean ischemia time (23.0-15.2 min, P < 0.01) decreased while tumor size (2.4-3.4 cm, P = 0.02) and nephrometry score (5.9-7.0, P = 0.02) increased. Body mass index (P = 0.87), age (P = 0.38), complication rate (P = 0.16), operating time (P = 0.78) and estimated blood loss (P = 0.98) did not change. Decreases in ischemia time corresponded with revised goals in 2011 and early vascular unclamping with the omission of cortical renorrhaphy in selected patients. A multivariable analysis found nephrometry score, tumor diameter, cortical renorrhaphy and year of surgery to be significant predictors of WIT.
  
  
  CONCLUSIONS
  Adoption of robotic assistance for a surgeon experienced with laparoscopic surgery was associated with low complication rates even during the initial cases of robot-assisted partial nephrectomy. Ischemia time decreased while no significant changes in blood loss, operating time or complications were seen. The largest decrease in ischemia time was associated with adopting evidence-based goals and new techniques, and was not felt to be related to a learning curve.
authors.affiliation: Department of Urology, Indiana University School of Medicine, Indianapolis, IN, USA.
authors.forename: Hitesh
authors.initials: H
authors.lastname: Dube
authors.affiliation: Department of Urology, Indiana University School of Medicine, Indianapolis, IN, USA.
authors.forename: Clinton D
authors.initials: CD
authors.lastname: Bahler
authors.affiliation: Department of Urology, Indiana University School of Medicine, Indianapolis, IN, USA.
authors.forename: Chandru P
authors.initials: CP
authors.lastname: Sundaram
keywords: Renal cell carcinoma; partial nephrectomy; robotics