UJ 35 Summer.pdf 562 | Learning Curve for Retroperitoneo- scopic Renal Pedicle Lymphatic Discon- nection for Intractable Chyluria A Single Surgeon’s Experience Long Wang,1 Zhenyu Ou,1 Hequn Chen,1 Zhenzhen Cao,2 Zhengyan Tang,1 Xiang Chen,1 Xiongbing Zu,1 Longfei Liu,1 Lin Qi1 Long Wang and Zhenyu Ou contributed equally to this work. Purpose: To evaluate the surgical experience and outcomes of retroperitoneoscopic renal pedicle - Materials and Methods: - - to document the learning curve for the procedure. Results: in the operation time (P = .000) and the blood loss (P did not differ in terms of demographic data, peri-operative complications, gastrointestinal recovery time, extubation time, or hospitalization duration. Conclusion: reproducible procedure. This study of the learning curve of a single surgeon suggests that competence at performing RRPLD is reached after approximately 20 cases. Keywords: Corresponding Author: Lin Qi, MD; PhD Department of Urology, Xiangya Hospital, Central South University, No.87 Xiangya Road, Changsha, Hunan 410008, China Tel: +86 138 7315 1645 Fax: +86 731 8432 7242 E-mail: xyurology@gmail. com Received September 2011 Accepted April 2012 1Department of Urology, Xiangya Hospital, Central South University, Changsha, China 2Department of Gyneco- logic Oncology, Hunan Provincial Tumor Hospital, Changsha, China LAPAROSCOPIC UROLOGY Laparoscopic Urology 563Vol. 9 | No. 3 | Summer 2012 |U R O LO G Y J O U R N A L INTRODUCTION hyluria is the passage of chyle into the urine urinary tract and the lymphatic system. The most common cause of chyluria is a parasitic infection, especial- ly Wuchereria bancrofti. Other non-parasitic causes, such as neoplasia, lymphatic malformation, abdominal trauma, or tuberculosis, are occasionally seen.(1)Although chyluria - quently seen in Asian countries. Some patients can obtain satisfactory curative effects through conservative measures, including dietary manage- - - tervention.(2) (3) the - plications, and rapid postoperative recovery, has been uti- lized more and more as the alternative surgical technique for chyluria. - curve, and the learning curve for each procedure can be (4-6) the learning curve for retroperitoneoscopic renal pedicle lymphatic disconnection (RRPLD) has not been reported of the learning curve on peri-operative outcomes in 40 con- number of cases needed to achieve reasonable results using a laparoscopic approach to perform renal pedicle lymphatic disconnection. MATERIALS AND METHODS - - - The surgeon has been trained primarily in open surgery, and has had some advanced laparoscopic training during fel- a fatty meal revealed chyluria from the left ureter in 24, the Age, gender, involvement site (left or right), body mass in- - plications, gastrointestinal recovery time, extubation time, and the last port closure. Surgical Procedure All the patients received general anesthesia, and routine lat- - th costal - - itoneum ventrally and separate the space. The creation of a introduced 2 cm above the iliac crest. Another 5-mm and - lary line under the 12th rib and the initial lumbotomy inci- 2 - nally close to the psoas magnum muscle. After removing the adipose capsule carefully, the surrounding fat tissues on - pletely bare after adequately stripping the circumambient fatty and connective tissues containing lymphatic vessels disconnected using ultrasonic scissors or ligated by titani- Learning Curve for Retroperitoneoscopic Surgery | Wang et al 564 | - - - rant arteries. To prevent tension on the renal vessels and iliac crest into the retroperitoneum. Learning Curve for Surgery operation time, blood loss, and other peri-operative pa- because surgical times reached a plateau around the 20th patient. Statistical Analysis - independent samples t test, Mann-Whitney U test, or Pear- - P value less than .05. RESULTS - formed laparoscopically by a beginner surgeon (conversion - - of illness in the left or right sides. - B C Figure 1. (A) Disconnection of lymphatic vessels around the ure- ter (arrow); (B) Disconnection of lymphatic vessels around the re- nal artery (arrow); (C) Disconnection of lymphatic vessels around the renal vein (arrow). Laparoscopic Urology 565Vol. 9 | No. 3 | Summer 2012 |U R O LO G Y J O U R N A L Learning Curve for Retroperitoneoscopic Surgery | Wang et al the 20th last 20 (90.5 versus 69.0 minutes, P = .000). The median 37.0 mL, P = .006). 1), 2 inadvertent minor rupture of the inferior vena cava, Gastrointestinal recovery, extubation, and hospitalization the operations. The urine chyle test became negative in all no gross chyluria reappeared in all the patients. DISCUSSION - (1) not responding to conservative measures requires surgical (7) With the advent and the subsequent popularity of laparosco- - (3) described retroperitoneoscopic lymphatic management of Several clinical trials demonstrated that RRPLD has many advantages over open surgery, including minimal invasion, less blood loss, shorter postoperative hospital stay, and rap- id recovery.(9-11) the standard of care for intractable chyluria in many institu- tions. The present study demonstrated that RRPLD is a re- producible, safe technique requiring a short learning curve to achieve satisfying results in terms of operation duration number of cases required for a surgeon to perform a par- Figure 2. Operation time according to surgeon’s experience. O p er at io n ti m e (m in ) Surgeon experience Table 1. Clinical characteristics of the analyzed patients. Variables Group 1 (cases 1 to 20) Group 2 (cases 21 to 40) P Age, y 50.3 ± 12.7 47.4 ± 9.7 .416 Body mass index, kg/m2 17.8 ± 2.1 18.5 ± 1.6 .242 Women/men 7/13 7/13 .000 Left/right side 13/7 13/9* .694 *2 patients with bilateral chyluria Table 2. Correlation of surgeon’s experience with clinical outcomes. Groups Operation time, min Blood loss, mL Gastrointestinal recovery time, hr Extubation time, hr Hospitalization time, day Overall Compli- cations, n (%) Group 1 90.5 (82.0 to 102.5) 55.0 (42.5 to 72.5) 24.0 (14.3 to 39.0) 28.2 (15.3 to 36.0) 4.0 (3.1 to 5.3) 3 (15.0) Group 2 69.0 (64.0 to 76.0) 37.0 (29.0 to 50.0) 29.5 (17.3 to 39.3) 31.5 (17.5 to 32.0) 4.5 (2.8 to 5.0) 2 ( 9.1) All cases 77.5 (69.0 to 89.0) 46.5 (35.0 to 67.0) 28.0 (15.0 to 38.5) 29.0 (16.5 to 33.5) 4.3 (3.2 to 5.1) 5 (11.9) P .000 .006 .735 .815 .513 .656 566 | ticular procedure to stabilize operation times and achieve acceptable outcomes.(12) - erated by a single beginner surgeon and divided them into 2 groups according to the change tendency of operation time. Therefore, potential statistic errors arising from different laparoscopists, centers, criteria, and surgical procedures - ing operation duration, complication rates, and blood loss duration and the blood loss range from 65 to 120 minutes able to delineate a learning curve of approximately 20 cases - Overall complication analysis is another important param- eter in estimating the safety of a surgical procedure during - erature are quite variable, ranging from 0% to 50% (Table - age in their series(13) despite the fact that a higher incidence had been reported in their previous research.(14) Seven pub- lished series reported that complications, including inferior vena cava injury, clipping of an auxiliary artery, and post- operative hematuria, occurred in a small number of patients in their series.(9-11,13-16) Similarly, the complications of the - - - - experience of RRPLD even in the early stages of the learn- ing curve. The present study demonstrated that gastrointes- tinal recovery and extubation and hospitalization times did - ence, suggesting that these parameters might not be suitable measures for assessing accredited laparoscopic surgeons. - ate number for a beginner surgeon to complete the learn- ing curve. These can be interpreted and explained in several - - Second, the experience acquired from other retroperitoneo- scopic surgeries, such as radical nephrectomy and live do- Table 3. Retroperitoneoscopic renal pedicle lymphatic disconnection: literature overview First Author (Ref number) Men /women Mean age, y Mean operation time, min Mean blood loss, mL Mean hospital- ization, day Major complications (n) Complication rate, % Hemal(14) 0/2 26.5 120 80 2.5 lymphatic leak (1) 50% Hemal(13) 6/3 36.5 111 95 2.6 lymphatic leak (1); clipping of post segmental artery branch (1) 22.2% Zhang(9) 3/4 49 65.0 29.3 4.7 postoperative hematuria (1) 14.3% Jiang(15) 4/2 42 95 85 7.2 clipping of auxiliary artery branch (1) 16.7% Zhang(10) 26/15 46.2 66.6 25 3.7 inferior vena cava injury (1) 2.4% Lan(11) 7/2 49 77 46 6 None 0% Xia(16) 31/47 56 92 55 6.8 inferior vena cava injury (1), clipping of an auxiliary artery (1) 2.6% Present series 14/26 50 80.9 50.0 4.5 inferior vena cava injury (2), clipping of an auxiliary artery (1), lymphatic leak (2) 11.9% Laparoscopic Urology 567Vol. 9 | No. 3 | Summer 2012 |U R O LO G Y J O U R N A L facilitates better execution of RRPLD. Third, Pre-operative of surgical videos for technical tips and pitfalls helped our team to improve step by step. The main limitation of this study is that the learning curve small sample size of 40 patients, limiting the generalizabil- learning curve varies depending on initial training and pre- - spread, as there is increasing information available in the literature, educational videos, and symposiums. Moreover, - (17) surgeons and maybe the duration for prospective mentor- ship by an experienced surgeon to optimize results. CONCLUSION Retroperitoneoscopic renal pedicle lymphatic disconnec- this procedure. During the learning curve period, excellent results in terms of operation time and blood loss can be outcome. CONFLICT OF INTEREST None declared 4. Tekkis PP, Senagore AJ, Delaney CP, Fazio VW. Evaluation of the learning curve in laparoscopic colorectal surgery: comparison of right-sided and left-sided resections. Ann Surg. 2005;242:83-91. 5. Neo EL, Zingg U, Devitt PG, Jamieson GG, Watson DI. Learn- ing curve for laparoscopic repair of very large hiatal hernia. Surg Endosc. 2011;25:1775-82. 6. Ahlberg G, Kruuna O, Leijonmarck CE, et al. Is the learning curve for laparoscopic fundoplication determined by the teacher or the pupil? Am J Surg. 2005;189:184-9. 7. Punekar SV, Kelkar AR, Prem AR, Deshmukh HL, Gavande PM. Surgical disconnection of lymphorenal communication for chyluria: a 15-year experience. Br J Urol. 1997;80:858-63. 8. Gomella LG, Shenot P, Abdel-Meguid TA. Extraperitoneal laparoscopic nephrolysis for the treatment of chyluria. Br J Urol. 1998;81:320-1. 9. Zhang X, Ye ZQ, Chen Z, et al. Comparison of open surgery versus retroperitoneoscopic approach to chyluria. J Urol. 2003;169:991-3. 10. Zhang X, Zhu QG, Ma X, et al. Renal pedicle lymphatic disconnection for chyluria via retroperitoneoscopy and open surgery: report of 53 cases with followup. J Urol. 2005;174:1828-31. 11. Lan WH, Jin FS, Wang LF, Zhu FQ. A comparison of retrop- eritoneoscopic and open surgical renal pedicle lymphatic disconnection for the treatment of serious filarial chyluria. Chin Med J (Engl). 2007;120:932-4. 12. Herrell SD, Smith JA, Jr. Robotic-assisted laparoscopic prostatectomy: what is the learning curve? Urology. 2005;66:105-7. 13. Hemal AK, Gupta NP. Retroperitoneoscopic lymphatic man- agement of intractable chyluria. J Urol. 2002;167:2473-6. 14. Hemal AK, Kumar M, Wadhwa SN. Retroperitoneoscopic nephrolympholysis and ureterolysis for management of intractable filarial chyluria. J Endourol. 1999;13:507-11. 15. Jiang J, Zhu F, Jin F, Jiang Q, Wang L. Retroperitoneoscopic renal pedicle lymphatic disconnection for chyluria. Chin Med J (Engl). 2003;116:1746-8. 16. Xia GW, Ding Q, Yu J, Xu K, Zhang YF. Retroperitoneoscopic renal pedical lymphatic disconnection in the treatment of chyluria. Chin Med J (Engl). 2008;121:1478-80. 17. Rosser JC, Jr., Lynch PJ, Cuddihy L, Gentile DA, Klonsky J, Merrell R. 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