The impact of assistant’s expertise on peri-operative outcomes in laparoscopic nephrectomy

October 2020

European Urology Open Science 20:S111

DOI:10.1016/S2666-1683(20)35488-4

Authors

D. Ndrevataj, Martina Beverini, Guglielmo Mantica, F. Ambrosini, Alberto Caviglia, Francesco Chierigo, F. Dotta, G. Guano, R. Malinaric, Andrea Pacchetti, Stefano Parodi, S. Rebuffo, Stefano Tappero, N. Testino, P. Traverso, Marco Borghesi, N. Suardi, Carlo Terrone

Full text

Introduction: Learning curve issues in laparoscopicnephrectomy (LN) has been widely addressed with regards with first surgeons’expertise. However, no studies have investigated the impact of assistant’s expertise on peri- and post-operative outcomes in laparoscopic nephrectomies. We tested the role of assistant’s expertise in a cohort of patients submitted to LN.

• Materials and methods: Between 2016 and 2020, all consecutive patients submitted to transperitoneal LN in a single institution by a single first surgeon were evaluated. Only LN performed for renal tumours were considered. Pre-, intra- and post-operative data were prospectively collected in the institutional database. The sample was divided in two groups according to the presence of an experienced (Group A) or inexperienced (Group B) assistant. Assistants were considered expert after the completion of 10 assisted procedures. Operative time (OT), blood loss (BL), intra- and peri-operative complications as well as length of stay (LS) were tested as outcomes. Variables considered for the analyses consisted of age, BMI, nephrectomy side as well as assistant’s expertise. Statistical analyses consisted of t-test for continuous variables and Chi-square test for categorical variable. Univariable and multivariable linear regression analyses were used to predict surgical time, blood loss and length of stay. Univariable and multivariable logistic regression analyses were used to predict the onset of post-operative complications. Covariates consisted of assistant’s experience, BMI, nephrectomy side and patients age.

  Results: 74 patients were enrolled in the study. Median (IQR) age of the sample was 66.5 [57–76] with a median BMI of 25.5 [21.8–27.5]. Group A consisted of 28 (37.8%) and group B consisted of 46 (62.2%) procedures, respectively. The two groups were not different in terms of age, gender, BMI and nephrectomy side. The median (IQR) BL was 100 [75–350] ml in Group A and 150 [100–200] in Group B ( p = 0.324); the median (IQR) OT was respectively 155 [135–207.5] min in Group A and 180 [147.5–233.5] min in Group B (p = 0.039), and the median LS was 4 [3–5] in Group A and 4 [4–5] in Group B (p =0.42). At multivariable linear regression analyses, after adjusting for BMI, nephrectomy side and patient age, assistant’s experience did not impact neither on BL (p = 0.36) nor on LOS (p = 0.6). Multivariable logistic regression did not show any correlation between assistant’s experience on post-operative complications (OR:0.98, p = 097). Conversely, a higher BMI and the presence of an assistant with lower experience represented independent predictors of longer OT (OR: 1.15; p = 0.042 and OR:5.05; p = 0.012; respectively).

  Conclusions: When LN is performed by an expert surgeon, the enrollment of trainees during their learning curve may results in longer OT but do not significantly impact intra- and peri-operative outcomes. Therefore, experienced surgeons may be assisted by trainees with benefits in terms of both assistants’learning curve

  without compromising patients’safety.