Positive surgical margin rates during the robot-assisted laparoscopic radical prostatectomy learning curve of an experienced laparoscopic surgeon

Abstract

Introduction: Since its introduction, robot-assisted laparoscopic radical prostatectomy (RARP) has gained widespread popularity, but is associated with a variable learning curve. Herein, we report the positive surgical margin (PSM) rates during the RARP learning curve of a single surgeon with significant previous laparoscopic radical prostatectomy (LRP) experience. Methods: We performed a prospective cohort study of the first 400 men with prostate cancer treated with RARP by a single surgeon (BS) with significant LRP experience. Our primary outcome was the impact of case timing in the learning curve on margin status. Our analysis was conducted by dividing the case numbers into quartiles (Q1-Q4) and determining if a case falling into an earlier quartile had an impact on margin status relative to the most recent quartile (Q4). Results: The Q1 cases had an odds ratio for margin positivity of 1.74 compared to Q4 (p=0.1). Multivariate logistic regression did not demonstrate case number to be a significant predictor of PSM. The mean Q1 operative time was 207.4 minutes, decreasing to 179.2 by Q4 (p<0.0001). The mean Q1 estimated blood loss was 255.1 ml, decreasing to 213.6 by Q4 (p=0.0064). There was no change in length of hospitalization within the study period. Conclusions: Even when controlling for copredictors, a statistically significant learning curve for PSM rate of a surgeon with significant previous LRP experience was not detected during the first 400 RARP cases. We hypothesize that previous LRP experience may reduce the RARP PSM learning curve.

Analysis of the Learning Curve of Surgeons without Previous Experience in Laparoscopy to Perform Robot-Assisted Radical Prostatectomy

“…With respect to location, 52.4% of the SM+ cases were apical, while we found that the majority of the compromised surgical margins were radial, perhaps due to an exaggerated attempt to achieve good neural preservation. In that other study, there was no significant difference in the SM+ rate as the number of cases progressed, possibly because the surgeon already had good experience in LRP [ 13 ].…”

The learning curves of major laparoscopic and robotic procedures in urology: A systematic review

“…Thirty-nine studies 18 , 20 , 24 – 60 evaluated the learning curve of RALP. While the majority of RALP studies focussed on defining the learning curve for OT and positive surgical margins (PSMs), Alemozaffar et al .’s study 25 was unique in defining the learning curve for potency, demonstrating that surgeon experience correlated with improved sexual function at 5 months ( P =0.007) and 12 months ( P =0.061) up to a plateau phase of 250–300 nerve-sparing RALP cases.…”

Are urologic surgeons performing robot-assisted radical prostatectomy at the University of Alberta meeting surgical quality performance benchmarks? The PROCURE-02 quality assurance study

“…1,2 Previous data has shown a learning curve for cancer control and established between-surgeon variation in both cancer control and functional preservation. [3][4][5] Surgical quality performance outcomes (SQPO) have been recognized across many surgical disciplines as there has been increased emphasis on quality assurance (QA) and quality improvement. [6][7][8] The 2010 Canadian Urological Association (CUA) consensus guideline examining surgical quality performance for radical prostatectomy suggested benchmarks for radical prostatectomy including achieving an unadjusted pT2-R1 resection rate < 25%, blood transfusion rate < 10%, rectal injury rate < 1%, and 90-day mortality rate < 1%.…”