Advertisement

Author Response to Commentary on “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

  • Sumit Dave
    Correspondence
    Correspondence to: Sumit Dave, B1-112, Victoria Hospital, London Health Sciences Centre, Schulich School of Medicine and Dentistry, Western University London, Ontario, Canada.
    Affiliations
    Division of Urology, Department of Surgery, Schulich School of Medicine and Dentistry, Western University. London, Ontario, Canada
    Search for articles by this author
Published:September 26, 2022DOI:https://doi.org/10.1016/j.jpurol.2022.09.019
      The authors wish to thank the reviewer for their comments which are apt and relevant regarding the use of CUSUM analysis for operative learning curves. Specifically, that the CUSUM curve for operative time is likely to show a similar pattern for other surgeons, if they choose to construct the learning curve using their own means, because mathematically, subtracting the mean from each datapoint will eventually reach zero at the last datapoint. It is therefore true that if constructed on an objectively accepted mean other than one's own that the learning curve for individual surgeons may not necessarily reach the “competency” phase according to the well-accepted standard. The value however lies in identifying the cut points to monitor the learning progression of a single surgeon and would be even more beneficial if data from several centers or surgeons is combined in a CUSUM analysis. It is then going to be a valuable tool for assessing training progression when a well-accepted standard is not available as a reference. One additional important factor, which made the learning progression appear rapid in this study is the fact that a pyeloplasty is a very standardized procedure and although anatomical variations exist, they are much more infrequent than, for example, a hypospadias repair. The authors also acknowledge that operative time alone is a poor marker for competency, the value of the CUSUM analysis in setting alert and alarm levels for complications, is probably equally if not more valuable in assuring safe progression of the learning curve. However, in a universal funded healthcare system like Canada, there is value in showing a predictable decrease in operative times. The additional costs of new technology can be offset by decrease in operative times significantly, as each hour of operative room time, in our system, for example, conservatively is around 1200 Canadian dollars. This allows the surgeon initiating a new technique, in a universal healthcare model, to present a more efficient and palatable model to healthcare administrators. This is even more pertinent because despite some observational studies suggesting that robot-assisted approach is associated with a shorter length of stay than open pyeloplasty and a shorter learning curve than laparoscopic pyeloplasty, there is currently no Level 1 evidence to demonstrate a clear cost benefit advantage of a robot assisted approach for pediatric pyeloplasty versus a laparoscopic/open approach [
      • González S.T.
      • Rosito Tiago E.
      • Tur A.B.
      • Ruiz J.
      • Gozalbez R.
      • Maiolo A.
      • et al.
      Multicenter comparative study of open, laparoscopic and robotic pyeloplasty in the pediatric population for the treatment of ureteropelvic junction obstruction (UPJO).
      ,
      • Greenwald D.
      • Mohanty A.
      • Andolfi C.
      • Gundeti M.S.
      Systematic review and meta-analysis of pediatric robot-assisted laparoscopic pyeloplasty.
      ].
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Journal of Pediatric Urology
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • González S.T.
        • Rosito Tiago E.
        • Tur A.B.
        • Ruiz J.
        • Gozalbez R.
        • Maiolo A.
        • et al.
        Multicenter comparative study of open, laparoscopic and robotic pyeloplasty in the pediatric population for the treatment of ureteropelvic junction obstruction (UPJO).
        Int Braz J Urol. 2022 Sep 9; : 48https://doi.org/10.1590/S1677-5538.IBJU.2022.0194
        • Greenwald D.
        • Mohanty A.
        • Andolfi C.
        • Gundeti M.S.
        Systematic review and meta-analysis of pediatric robot-assisted laparoscopic pyeloplasty.
        J Endourol. 2022 Apr; 36: 448-461

      Linked Article

      • The opportunities and cautions of cumulative sum analysis in assessing learning curves in pediatric urology
        Journal of Pediatric UrologyVol. 18Issue 6
        • Preview
          In this issue of the Journal of Pediatric Urology, Stern et al. present on an experienced laparoscopic surgeon's experience in adopting the robotic-assisted platform for pediatric pyeloplasty [1]. This manuscript can be read at multiple levels. First, the authors nicely demonstrate both overall and task-specific learning curves for surgeons adapting the robotic technique. While the robotic platform has already saturated many marketplaces, this is relevant work for those areas where the surgical robot still represents an emerging opportunity.
        • Full-Text
        • PDF