Pediatric Robotic-assisted Laparoscopic Pyeloplasty: Defining Mastery Over a 15 Year Experience

Background: Robotic-assisted laparoscopic pyeloplasty (RALP) has been widely utilized within pediatric urology as RALP provides additional advantages to laparoscopic pyeloplasty including a more manageable learning curve. We aim to describe the maturation and mastery of pediatric RALP through our proposed trifecta of operative time, complication rates, and surgical success rates.

Methods: We retrospectively reviewed 148 patients who underwent RALP between 2007 and 2022. Primary outcomes included operative time, Clavien-Dindo Grade (CDG) III complications, and surgical success rate. Patients were retrospectively divided into three cohorts (learning phase, competency phase, and mastery phase) based upon a cumulative sum (CUSUM) analysis of operative time.

Results: Three learning phases were differentiated at case 13 and case 41 per CUSUM analysis. Operative time significantly decreased from a mean of 261.33 ± 42.52 min in the learning phase to 140.61 ± 25.87 min in the mastery phase (p < 0.001). CDG III complications were significantly different between phases as well, decreasing from 27.3 % to 5.75 % (p = 0.045). Success rates were significantly different and increased from 83 % in the learning phase to 98 % in the mastery phase (p = 0.015).

Conclusion: Successful RALP implementation, and the achievement of surgical mastery, is multifaceted and multi-phasic. Our data suggests that learning is established within the first 12 cases and mastery and maximal outcomes are achieved after 41 cases. More specifically, operative time, complication rates, and success rates become increasingly optimized at each phase of learning. Our work can be used to establish clinical goals, design training curriculums, and inform patient counseling.

Level Of Evidence: Level III.