累积和分析法分析机器人辅助腹腔镜儿童肾盂成形术的学习曲线

Learning curve of pediatric robotic-assisted laparoscopic pyeloplasty through cumulative sum analysis

目的分析机器人辅助腹腔镜肾盂成形术的学习曲线规律。方法回顾性分析2020年7月至2022年2月在浙江大学医学院附属儿童医院由同一名主刀医生完成的机器人辅助腹腔镜肾盂成形术50例患儿的临床资料。其中男35例,女15例;年龄为(57.3±44.6)个月;患肾位于左侧34例,右侧16例;记录每例的机器人手术时间、肾盂输尿管连接部吻合时间。采用累积和分析法分析机器人手术时间和肾盂输尿管连接部吻合时间的学习曲线,以R2判断拟合优度。比较学习曲线不同阶段各观察指标的差异。结果50例患儿均在机器人辅助腹腔镜下完成手术,无中转开放。机器人手术时间为(95.0±19.0)min,肾盂输尿管连接部吻合时间为(45.5±8.5)min。术后发生并发症共8例,其中Clavien-Dindo分级Ⅰ~Ⅱ级6例,Ⅲ级2例;患儿随访时间为(10.3±5.6)个月,范围在3~22个月,随访期间3例患儿肾盂前后径进行性增加或较术前无改变,手术成功率为94%(47/50)。50例患儿手术时间拟合曲线在手术例数累积至第18例时达到顶点,以此为分界将学习曲线划分为学习提高阶段和熟练掌握阶段,机器人手术时间和肾盂输尿管连接部吻合时间均随着手术例数的增加呈现逐渐下降的趋势。学习提高阶段和熟练掌握阶段的机器人手术时间分别为(108.2±24.4)min和(88.2±11.1)min,差异有统计学意义(t=3.20,P=0.005)。学习提高阶段和熟练掌握阶段的肾盂输尿管连接部吻合时间分别为(52.0±9.5)min和(41.8±5.4)min,差异有统计学意义(t=4.17,P<0.001)。学习提高阶段和熟练掌握阶段的患儿年龄、体重、术后引流管及尿管留置时间、术后住院时间差异均无统计学意义(均P>0.05)。结论对于已具备丰富的传统腹腔镜肾盂成形术经验的医生,跨越机器人辅助腹腔镜肾盂成形术学习曲线的最低手术例数是18例。

Objective To explore the clinical value of learning curve of pediatric robot-assisted laparoscopic pyeloplasty(RALP).Methods A retrospective study was conducted for collecting clinical data of 50 children undergoing RALP performed by the same surgeon from July 2020 to February 2022.There were 35 boys and 15 girls with a mean age of(57.3±44.6)months.The involved side was left(n=34)and right(n=16).Operative duration and ureteropelvic junction(UPJ)anastomosis time were recorded.Cumulative sum analysis was utilized for examining the learning curve of operative duration and UPJ anastomosis time.The differences of observation parameters at different stages of the learning curve were compared.Results RALP was performed without any conversion to open surgery.Operative duration was(95.0±19.0)min and UPJ anastomosis time(45.5±8.5)min.Among 8 cases of postoperative complications,there were Clavien-Dindo gradeⅠ-Ⅱ(n=6)and gradeⅢ(n=2).During an average follow-up period of(10.3±5.6)(3-22)months,anteroposterior diameter of renal pelvis spiked progressively or stayed unchanged as compared with pre-operation in 3 children.The success rate was 94%(47/50).The fitting curve of operative duration peaked in Case 18.The learning curve was divided into stages of learning improvement and proficiency.There was a gradual downward trend with more operations.There was significant difference between learning improvement and proficiency stages[operative duration:(108.2±24.4)vs(88.2±11.1),P=0.005;anastomosis time:(52.0±9.5)vs(41.8±5.4),P<0.001].No significant differences existed between two stages in age,weight,postoperative drainage tube or urinary catheter indwelling time or postoperative hospital stay(all P>0.05).Conclusions For surgeons with extensive experience in traditional laparoscopic pyeloplasty,the minimal number of RALP learning curve is 18.