surgeons performing lpn must not only possess advanced intracorporeal suturing skills , but must also operate efficiently under the time constraints of warm ischemia . when first reported in the 1990s , lpn was associated with high complication rates , including hemorrhage , urinary fistula , and open conversion . surgeons who have received fellowship training at high - volume centers with extensive lpn experience are performing lpns early in their careers . however , limited outcome data exist for these surgeons , and it is unclear whether , immediately after training , they achieve results comparable to those of their mentors . in addition , because robot - assisted partial nephrectomy is being investigated and even promoted as a procedure for surgeons without formal laparoscopic training , it is critical to better define skills obtainable from traditional laparoscopic training programs . this study documents the outcomes of lpn as performed by 3 surgeons in the initial years of independent practice following fellowship training . three prospectively maintained renal tumor databases were queried for lpns performed during the first 3.5 years of practice . all primary surgeons ( sfm , le , hlk ) completed urologic fellowships between 2001 and 2004 . each had trained with surgeons experienced in performing lpns and participated in at least 10 lpns during their fellowship . although the level of participation varied during each case , typically as fellows , these surgeons mobilized the kidney and hilum laparoscopically while their mentors performed the tumor excision and renorrhapy . operative data included total operative time , warm ischemia time ( wit ) , tumor size , depth of invasion , estimated blood loss ( ebl ) , reason for conversion , and postoperative complications . tumors seen abutting the collecting system or renal hilum on ct scan were considered to be central . tumor excision and renorrhapy was performed under warm ischemic conditions by placing a laparoscopic satinsky clamp on the renal artery only . repair of the tumor bed was accomplished by using a single layer of 0-vicryl sutures on cpx needles , placed in a figure - of-8 fashion and held in place with lapra - ty clips ( ethicon , piscataway , nj ) . each stitch was passed under the entire tumor bed , thereby closing the collecting system and achieving hemostasis simultaneously ; no bolsters were used . briefly , all cases were performed transperitoneally except for lower pole or posterior renal masses that were approached retroperitoneally . suture repair of the defect was performed over a fibrillar bolster and surgifoam powder ( ethicon , piscataway , nj ) . in select cases , a hand - assisted approach was preferred . in all cases , the hilum was controlled by using a laparoscopic bulldog clamp on the renal artery under warm ischemic conditions . the tumor bed was coagulated with a floating ball electrode ( endo fb3.0 ) ( salient surgical technologies , dover , nh ) . when necessary , the collecting system was closed by using 3 0 absorbable suture on an sh needle . the tumor bed was then covered with a layer of surgifoam ( ethicon , piscataway , nj ) . renorrhaphy was then performed using surgicel bolsters held in place with 0  0 absorbable sutures on a ct-1 needle secured by lapra - ty clips ( ethicon , piscataway , nj ) . data regarding intraoperative parameters , oncological efficacy , and postoperative complications were analyzed collectively with reported means representing the average of all surgeons at each case number . because cases performed were not equal for all surgeons , some means represented the average of data for fewer than 3 surgeons . fisher 's exact test was used to compare proportions , and the student t test was used to compare means . operative data included total operative time , warm ischemia time ( wit ) , tumor size , depth of invasion , estimated blood loss ( ebl ) , reason for conversion , and postoperative complications . tumors seen abutting the collecting system or renal hilum on ct scan were considered to be central . tumor excision and renorrhapy was performed under warm ischemic conditions by placing a laparoscopic satinsky clamp on the renal artery only . repair of the tumor bed was accomplished by using a single layer of 0-vicryl sutures on cpx needles , placed in a figure - of-8 fashion and held in place with lapra - ty clips ( ethicon , piscataway , nj ) . each stitch was passed under the entire tumor bed , thereby closing the collecting system and achieving hemostasis simultaneously ; no bolsters were used . briefly , all cases were performed transperitoneally except for lower pole or posterior renal masses that were approached retroperitoneally . suture repair of the defect was performed over a fibrillar bolster and surgifoam powder ( ethicon , piscataway , nj ) . le performed lpn primarily using a transperitoneal or retroperitoneal pure laparoscopic approach . in select cases , the hilum was controlled by using a laparoscopic bulldog clamp on the renal artery under warm ischemic conditions . the tumor bed was coagulated with a floating ball electrode ( endo fb3.0 ) ( salient surgical technologies , dover , nh ) . when necessary , the collecting system was closed by using 3 0 absorbable suture on an sh needle . the tumor bed was then covered with a layer of surgifoam ( ethicon , piscataway , nj ) . renorrhaphy was then performed using surgicel bolsters held in place with 0  0 absorbable sutures on a ct-1 needle secured by lapra - ty clips ( ethicon , piscataway , nj ) . data regarding intraoperative parameters , oncological efficacy , and postoperative complications were analyzed collectively with reported means representing the average of all surgeons at each case number . because cases performed were not equal for all surgeons , some means represented the average of data for fewer than 3 surgeons . fisher 's exact test was used to compare proportions , and the student t test was used to compare means . females accounted for 48 ( 35% ) of the 136 patients ( 2 patients had staged bilateral lpns ) . the primary surgeon was hlk in 60 , sfm in 60 , and le in 18 . mean patient age was 57 years ( range , 29 to 91 ) , mean tumor size was 2.52 cm ( range , 0.6 to 7 ) , mean depth of invasion was 1.68 cm ( range , 0.4 to 3.9 ) , and 28 ( 20% ) tumors were central in location . the majority of procedures ( 96% ) were successfully completed laparoscopically , with mean or time of 252 minutes ( range , 135 to 388 ) , mean wit 26 minutes ( range , 0 to 55 ) , and mean ebl 202 ml ( range , 20 to 1700 ) . complications occurred in 7 patients ( 5% ) : hemorrhage requiring transfusion in 3 patients ( 2% ) , urinary fistula in 1 patient ( 1% ) , rhabdomyolysis that spontaneously resolved without the need for dialysis in 1 patient ( 1% ) , pyelonephritis in 1 patient ( 1% ) , and injury to the ivc that was repaired laparoscopically in 1 patient ( 1% ) . indications for the 9 conversions included bleeding ( 3 cases ) , presence of multiple tumors on intraoperative ultrasound ( 1 case ) , significant perirenal fibrosis ( 3 cases ) , discovery of segmental renal vein tumor thrombus ( 1 case ) , and positive margins on frozen section ( 1 case ) . the conversions were to laparoscopic radical nephrectomy ( lrn ) in 4 cases and open partial nephrectomy ( opn ) in 5 cases . pathology revealed renal cell carcinoma ( rcc ) in 99 ( 72% ) patients , and positive surgical margins in 2 patients ( 1% ) . at median follow - up of 11 months , no patients had evidence of local recurrence . both patients with positive surgical margins demographic and surgical parameters are summarized and compared with those of more experienced centers in table 1 . comparison of demographic and surgical characteristics the influence of case number on 4 operative parameters is summarized in table 2 . with experience , there was a significant reduction in mean or time ( 204 min vs. 253 min , p=0.007 ) and mean wit ( 24 min vs. 32 min , p<0.001 ) . however , there was no significant change for mean tumor size ( 2.6 cm vs. 2.4 cm , p=0.390 ) or mean ebl ( 226 ml vs. 220 ml , p=0.922 ) . laparoscopic partial nephrectomy operative parameters as a function of experience or = operating room ; wit = warm ischemia time ; ebl = estimated blood loss . comparing first 15 cases to last 15 cases . to explore the learning curve for lpn , scatter plots were constructed to demonstrate the relationship between 4 operative parameters and case number ( figure 1 ) . parameters showing a statistically significant change with increasing experience ( or time and wit ) were fitted with logarithmic curves . parameters that did not change significantly with increasing case number were fitted with linear regression equations . for ebl , the line showed a negative slope of 1.12 ( p=0.39 ) , and for tumor size it showed a positive slope of 0.01 ( p=0.06 ) . operative time ( a ) and warm ischemia time ( b ) decreased with experience , and the plots were fitted with a logarithmic curve . tumor size ( c ) and estimated blood loss ( d ) did not demonstrate significant change with experience , and the plots were fitted with linear regression . contemporary outcomes of lpn have improved significantly since the original description of this operation by winfield in 1995 . turna and associates recently analyzed more than 500 patients treated with lpn and found a significant reduction in complications with experience , despite treatment of larger and more complex tumors . kavoussi and associates reviewed 345 patients undergoing lpn and found a 28% complication rate , and 80% of these were deemed minor . the current study suggests that fellowship training under the tutelage of experienced surgeons allows urologists to achieve favorable outcomes in their initial years of independent practice . the positive margin rate ( 1% ) , and overall complication rate ( 5% ) are comparable to that reported in other published reports from high - volume surgeons . the surgeons in the current study had the benefit of using techniques already refined by their mentors . they may also have minimized their complications by using liberal indications for converting to laparoscopic radical nephrectomy ( 3% ) or open partial nephrectomy ( 4% ) . to assess the learning curve for fellowship - trained urologists , the current study examined changes in 4 key operative parameters as a function of case number . the scatter plots and fitted lines in figure 1 suggest that , for recently fellowship - trained surgeons , there is in fact a learning curve for lpn with regards to operative time and warm ischemia time . however , both parameters improved quickly , as evidenced by flattening of the fitted curves . increased experience was associated with an increase in tumor size that was not statistically significant . in contrast , blood loss was minimally affected by increased experience , suggesting that all 3 surgeons largely mastered techniques to minimize blood loss during their fellowships . surgeons in this study used intraoperative ultrasound to plan tumor excision and help achieve negative margins . in the current study , use of the equipment and interpretation of images was performed by the operating surgeon without assistance from a radiologist . intraoperative ultrasound was particularly useful for localizing endophytic tumors and those tumors densely encased in perinephric fat . although the current study documents the outcomes of lpn by recently fellowship - trained urologists , residents finishing some urology training programs are graduating with similar exposure to lpn . however , caution must be exercised in extrapolating the findings of the current study to residency training . fellowship provides a dedicated and focused laparoscopy experience and hence a foundation for performing more complex cases after training . this may explain why fellowship - trained surgeons in the current study were able to perform lpns despite what appears to be limited exposure to the procedure during their training . bhayani reported no significant differences in outcomes of his first 25 lpns compared with his last 25 lpns , except for length of hospitalization , with an overall complication rate of 16% . there were no open conversions , and the urological complication rate was 13.3% . with regard to the learning curve for lpn , link et al found a trend toward shorter or times with the increasing number of cases performed similar to the current study . favorable outcomes have been reported by recently fellowship - trained surgeons for other complex laparoscopic procedures . rosser showed that 2 recently fellowship - trained surgeons performing radical prostatectomy within their first year of practice were able to achieve oncological outcomes and complication rates similar to those of more experienced surgeons . with regard to laparoscopic donor nephrectomies , sajadi and associates showed fellowship training in laparoscopy allowed for favorable operative results of donor nephrectomies and long - term graft survival . proposed benefits of fellowship training with regard to patient outcomes after laparoscopic gastric bypass include shorter operative times , lower complication rates , and lower mortality rates . these studies suggest that fellowship training places a new surgeon high on the learning curve for complex laparoscopic operations , and allows them to perform these procedures with favorable outcomes . specifically , the study relied on data from surgeons from different institutions , who may have used differing criteria to record and grade complications . secondly , the study does not have a direct comparison arm , such as a group of surgeons performing lpn without fellowship training . lastly , the disparity in the case volume between the 3 surgeons and differences in surgical technique could have affected analysis of the learning curve for lpn . mean values for all surgeons at each case number were used to minimize this effect . newly fellowship - trained surgeons performing lpn achieve initial outcomes comparable to those reported by highly experienced surgeons . further experience reduced total operative and warm ischemia times .
background and objectives : experienced surgeons at select high - volume centers have reported favorable outcomes of laparoscopic partial nephrectomy ( lpn ) in their contemporary experience . however , it is unclear whether recently fellowship - trained surgeons can replicate such outcomes . 
 we evaluated lpns performed by 3 surgeons in their initial years of independent practice following laparoscopic fellowship training.methods:prospectively maintained databases were queried for lpns performed during the first 3.5 years of practice . 
 intraoperative parameters , oncological efficacy , and postoperative complications were analyzed.results:of 138 total lpns ( 76 left , 62 right ) , the mean patient age was 57 years , mean tumor size was 2.52 cm , and mean depth of invasion was 1.68 cm . 
 mean or time was 252 minutes , mean warm ischemia time ( wit ) was 26 minutes , and mean estimated blood loss ( ebl ) was 202 ml . 
 complications occurred in 7 patients ( 5% ) , and conversions occurred in 9 patients ( 7% ) . 
 comparison of the first 15 vs. the last 15 cases demonstrated a significant reduction in mean or time ( 204 min vs. 253 min , p=0.007 ) , and mean wit ( 24 min vs. 32 min , p<0.001 ) . 
 no significant change was demonstrated for tumor size ( 2.6 cm vs. 2.4 cm , p=0.390 ) or ebl ( 226 ml vs. 220 ml , p=0.922).conclusion : newly fellowship - trained surgeons performing lpn achieve initial outcomes comparable to those reported by highly experienced surgeons . 
 further experience reduced total operative and warm ischemia times .