The following is the summary of “A cumulative sum (CUSUM) analysis studying operative times and complications for a surgeon transitioning from laparoscopic to robot-assisted pediatric pyeloplasty: Defining proficiency and competency” published in the December 2022 issue of Pediatric urology by Stern, et al.

There is a risk that operating times and healthcare expenses may rise when hospitals move from laparoscopic to robot-assisted surgeries. Objectively studying the learning curve with cumulative sum (CUSUM) analysis allows for detecting major changes in operative timing and the monitoring complication rates. The purpose of this study is to examine the learning curve of a single surgeon making the switch from laparoscopic to robot-assisted pyeloplasty (RAP) in children. 50 consecutive RAP procedures conducted between June 2013 and January 2019 were included in this prospective cohort analysis. For this purpose, we used piecewise linear regression to analyze the CUSUM of RAP total operative time (OT) to identify the transition points between the various stages of learning. 

With 5% acceptable and 10% unacceptable complication rates, a cumulative-observed-minus-expected failure chart was created with 80% and 95% reassuring borderlines. An impartial observer timed each operation step, including port insertion, dissection, hitch stitch placement, pelvic dismemberment and spatulation, suturing, and port removal. Breakpoints between Learning and Proficiency, and Proficiency and Competence were found using piecewise linear regression for OT in cases 13 and 29. Total OT was 142.2 46.0 minutes, on average. However, the average OT varied significantly (p 0.001) between the three stages of learning, from 203.9 35.3 minutes (first 13 cases) to 159.2 18.6 minutes (middle 16 cases) to 126.6 19.7 minutes (final 21 cases). Until case 41, the rate of RAP complications hovered around the tolerable threshold of 5%, eventually settling at 8% overall. 

According to the step-by-step study, case 27 was identified as the transition point from learning to competence in suturing, with a 50% reduction in suturing time throughout the 3 stages. According to our findings, by the 30th case, a surgeon switching to RAP will have substantially reduced OT by a substantial amount. Consistently low complication rates suggest that RAP can be implemented safely, even at low-volume centers. Early considerable decrease in suturing times seen between the Learning and Proficiency stages suggests suturing competency is a significant advantage of the robotic platform. To help surgeons and residents switch from laparoscopic to RAP, further research can validate these results and provide reference operative times. Also, overall, OT drops noticeably and rapidly after switching to RAP.

Source: sciencedirect.com/science/article/abs/pii/S1477513122003278