title: Robotic partial nephrectomy - Evaluation of the impact of case mix on the procedural learning curve.
abstract: BACKGROUND
  Although Robotic partial nephrectomy (RPN) is an emerging technique for the management of small renal masses, this approach is technically demanding. To date, there is limited data on the nature and progression of the learning curve in RPN.
  
  
  OBJECTIVE
  To analyse the impact of case mix on the RPN LC and to model the learning curve.
  
  
  METHODS
  The records of the first 100 RPN performed, were analysed at our institution that were carried out by a single surgeon (B.C) (June 2010-December 2013). Cases were split based on their Preoperative Aspects and Dimensions Used for an Anatomical (PADUA) score into the following groups: 6-7, 8-9 and >10. Using a split group (20 patients in each group) and incremental analysis, the mean, the curve of best fit and R(2) values were calculated for each group.
  
  
  RESULTS
  Of 100 patients (F:28, M:72), the mean age was 56.4 ± 11.9 years. The number of patients in each PADUA score groups: 6-7, 8-9 and >10 were 61, 32 and 7 respectively. An increase in incidence of more complex cases throughout the cohort was evident within the 8-9 group (2010: 1 case, 2013: 16 cases). The learning process did not significantly affect the proxies used to assess surgical proficiency in this study (operative time and warm ischaemia time).
  
  
  CONCLUSIONS
  Case difficulty is an important parameter that should be considered when evaluating procedural learning curves. There is not one well fitting model that can be used to model the learning curve. With increasing experience, clinicians tend to operate on more difficult cases.
authors.affiliation: MRC Centre for Transplantation, King's College London, Urology Centre, Guy's Hospital, London UK.
authors.forename: A
authors.initials: A
authors.lastname: Roman
authors.affiliation: MRC Centre for Transplantation, King's College London, Urology Centre, Guy's Hospital, London UK.
authors.forename: K
authors.initials: K
authors.lastname: Ahmed
authors.affiliation: MRC Centre for Transplantation, King's College London, Urology Centre, Guy's Hospital, London UK. Electronic address: benchallacombe@doctors.org.uk.
authors.forename: B
authors.initials: B
authors.lastname: Challacombe
mesh_terms: D000328:Adult; D000368:Aged; D002983:Clinical Competence; D003953:Diagnosis-Related Groups; D005260:Female; D006801:Humans; D059032:Learning Curve; D008297:Male; D008875:Middle Aged; D009392:Nephrectomy / Q000193:education / Q000379:methods / Q000523:psychology*; D061646:Operative Time; D012189:Retrospective Studies; D065287:Robotic Surgical Procedures / Q000193:education / Q000379:methods / Q000523:psychology*; D066231:Surgeons / Q000523:psychology*; D016896:Treatment Outcome; D052096:Warm Ischemia
keywords: Learning curve; Robotic partial nephrectomy