Institute of Urology, St. Luke's Medical Center , Quezon City , N.C.R. , Philippines.
Division of Urology, Hospital for Sick Children , Toronto , Ontario , Canada.
J Urol. 2019 Jun;201(6):1199-1205. doi: 10.1097/JU.0000000000000021.
We assessed achievement of competence in pediatric renal transplant by developing a learning curve model for consecutive operations performed by a single surgeon.
We retrospectively evaluated pediatric renal transplant cases performed by an index pediatric urologist during his first 15 years of being the primary transplant surgeon at our institution. Case characteristics, operative time and surgical complications within 30 days postoperatively were assessed and compared to those of a reference senior surgeon. To generate a learning curve plot, we performed a cumulative sum analysis to evaluate the evolution of operative times and surgical complications.
During 15 years 55 pediatric renal transplants (17%) were performed by the index surgeon and 78 (24%) by the senior surgeon. Total operative time was shorter for the index surgeon (226 vs 252 minutes, p = 0.006), while ischemia time was longer (40 vs 30 minutes, p = 0.001). The 30-day surgical complication rates were similar (32.7% and 35.9%, p = 0.853). The learning curve showed that the complication rates and operative times did not increase following the 17th case. Ureteroureterostomy has been more commonly performed for ureteral anastomosis (p = 0.048) and longer warm ischemia time has been noted after reaching the peak of the learning curve (p = 0.003).
We determined that technical skills for pediatric renal transplant can be achieved after the 17th case. We propose that a dedicated team with a pediatric urologist who has an interest in performing pediatric renal transplant secure more cases than the case volume determined in our study within the first few years of practice to maintain proficiency.
通过为一位外科医生连续进行的手术建立学习曲线模型，评估小儿肾移植的能力。
我们回顾性评估了一位主任小儿泌尿科医生在我院作为主要移植外科医生的前 15 年中进行的小儿肾移植病例。评估了病例特征、手术时间和术后 30 天内的手术并发症，并与一位参考资深外科医生进行了比较。为了生成学习曲线图，我们进行了累积和分析，以评估手术时间和手术并发症的演变。
在 15 年内，55 例小儿肾移植由主任外科医生完成（17%），78 例由资深外科医生完成（24%）。主任外科医生的总手术时间更短（226 分钟对 252 分钟，p = 0.006），而缺血时间更长（40 分钟对 30 分钟，p = 0.001）。30 天手术并发症发生率相似（32.7%和 35.9%，p = 0.853）。学习曲线表明，第 17 例之后并发症发生率和手术时间没有增加。输尿管吻合术更常采用输尿管-输尿管吻合术（p = 0.048），并且在达到学习曲线高峰后，热缺血时间延长（p = 0.003）。
我们确定，小儿肾移植的技术技能可以在第 17 例之后达到。我们建议，一个有兴趣进行小儿肾移植的小儿泌尿科医生组成的专门团队，在实践的头几年内获得比我们研究中确定的病例量更多的病例，以保持熟练程度。
