Robotic radical prostatectomy: difficult to start, fast to improve? Influence of surgical experience in robotic and open radical prostatectomy

Abstract

Purpose The assistance of robotic systems raises the concern of whether there is an improved learning in robotic-assisted radical prostatectomy (RARP) compared to open retropubic radical prostatectomy (ORP). Methods We retrospectively analyzed data from 1438 patients who underwent ORP (n = 735) or RARP (n = 703). For each procedure, the level of experience of three different surgeons was summarized. Perioperative and pathological parameters reflecting surgical performance were compared between both learning curves. RARP data were influenced by new introduction of the robotic system. Results The median patient age at surgery was 66 years (IQR 42–80). Patients in the RARP group were younger (p < 0.001) and had a lower oncological risk (p < 0.001). Inexperienced RARP surgeons had a higher pT2-PSM rate and lower lymph node yield (13.8 ± 4.7 vs. 14.7 ± 4.8; p = 0.03) than inexperienced ORP surgeons. After 100 procedures, RARP and ORP surgeons had the same pT2-PSM rate (8% vs. 8%; p = 0.8) and lymph node yield (15.4 ± 5.4 vs. 15.4 ± 5.1; p = 1.0). In multivariate analysis for ORP, surgical inexperience (≤ 100 cases) was an independent predictor of a longer operating time (OR 9.0; p < 0.001) and higher amount of blood loss (OR 2.9; p < 0.001). For RARP, surgical inexperience (≤ 100 cases) was a predictor of a longer operating time (OR 3.9; p < 0.001), higher amount of blood loss (OR 1.9; p = 0.004), higher pT2-PSM rate (OR 1.6; p = 0.03), and lower lymph node yield (OR 0.6; p = 0.001). Conclusions Surgical experience has a relevant impact on perioperative and pathological parameters RARP has a higher initial pT2-PSM rate and lower lymph node yield than ORP. This is relevant for patient selection for novice teaching in RARP.

Is the learning curve of the urology resident for conventional radical prostatectomy similar to that of staff initiating robot-assisted radical prostatectomy?

“…Recently, Baunack, et al ( 39 ) also compared learning groups of RARP and ORP. In it, the authors identified lower mean age and oncological risk for patients operated on with the robotic technique rather than the open technique.…”

“…Furthermore, Baunack, et al ( 39 ), identified that surgeons inexperienced in robotics obtained a higher percentage of PSM and lower yield of dissected lymph nodes. In our study, there was no statistically significant difference in PSM and dissected lymph nodes when comparing the two groups, which gives more credit to robotic surgery Furthermore, Baunack, et al ( 39 ), identified that surgeons inexperienced in robotics obtained a higher percentage of PSM and lower yield of dissected lymph nodes.…”

“…Furthermore, Baunack, et al ( 39 ), identified that surgeons inexperienced in robotics obtained a higher percentage of PSM and lower yield of dissected lymph nodes. In our study, there was no statistically significant difference in PSM and dissected lymph nodes when comparing the two groups, which gives more credit to robotic surgery Furthermore, Baunack, et al ( 39 ), identified that surgeons inexperienced in robotics obtained a higher percentage of PSM and lower yield of dissected lymph nodes. In our study, there was no statistically significant difference in PSM and dissected lymph nodes when comparing the two groups, which gives more credit to robotic surgery, and is in agreement with a recent study by Bravi et al ( 36 ), which also concluded that surgeons performing RARP achieve adequate cancer control in the early phase of their career.…”

“…It should be noted that the total number of lymph nodes is what matters in the analysis of surgeons' experiences, since the percentage of affected lymph nodes is much more related to the degree of the disease and not to the surgeon's expertise. In this sense, there are still no studies for the learning curve in lymphadenectomy ( 39 ), in open surgery, with only two studies for RARP ( 40 , 41 ), as far as we know.…”

Predicting Surgical Experience After Robotic Nerve-sparing Radical Prostatectomy Simulation Using a Machine Learning–based Multimodal Analysis of Objective Performance Metrics

“…[7][8][9] With a projected 288,300 new prostate cancer diagnoses in the United States for 2023 alone, 10 improving assessment and training of nervesparing RARP may substantially improve the quality of life for this patient population. RARP has well-defined milestones within its learning curve, with decreases in operative time after 100 cases, 11 and with erectile function preservation and negative surgical margin plateau beginning at 250 cases. 12 Objective performance indicators (OPIs) are metrics objectively derived from kinematic and event-based data collected from the da Vinci robotic system (Intuitive Surgical).…”