Teaching laparoscopic radical prostatectomy during the primary surgeon's early learning curve – analysis of our first 207 cases Serge Luke, Warick Delprado* and Mark Louie-Johnsun Department of Urology, Gosford Hospital and Gosford Private Hospital, Gosford, *Douglass Hanly Moir Pathology, Sydney, NSW, Australia
Objective To assess the feasibility of introducing laparoscopic radical prostatectomy (LRP) training during the primary surgeon’s early learning curve in a regional Australian centre.
Patients and methods From a prospective single surgeon database perioperative, oncological and functional outcome data was collected from the first 207 consecutive patients who underwent LRP immediately after a 12-month LRP Fellowship in a high-volume centre by the primary surgeon (M.L.J.). A training case was defined as the successful completion of at least two of 10 steps by a training Fellow. Perioperative and oncological outcomes were compared in training and non-training cohorts and overall learning curve was assessed by comparing consecutive 50-patient cohorts.
Operative times were significantly longer in training cases (mean 269 vs 209 min; P < 0.001). There was no statistically significant difference in perioperative outcomes of length of stay (2.7 vs 2.6 days), transfusion rates (3.1% vs 2.1%), major complication (Clavien >3a) rates (1.6% vs 2.1%) or positive surgical margins (PSMs: pT2 2.8% vs 15.3% and pT3 52.0% vs 45.1%) between training and non-training groups, respectively. Overall, there were two open conversions (1.0%).
Conclusion Despite the challenging learning curve, LRP training can be commenced safely with a stepwise modular approach, even when the primary surgeon is in their early learning curve. Perioperative outcomes including PSMs and major complications were unaffected by trainee involvement.
Results
Keywords
In all, 31% of cases were training cases with a median (range) of 7 (2–10) steps of 10 steps performed by the training Fellow.
laparoscopic radical prostatectomy, prostate cancer, training, learning curve
Introduction
Australasia and this is where most Australasian Fellows performing LRPs have been trained [8].
The steep learning curve of laparoscopic radical prostatectomy (LRP) is well recognised [1]. The initial experience of high-volume first generation surgeons have suggested that >200 cases may be required to overcome the learning curve for surgical margins [2,3] and up to 700 for the functional outcomes, such as potency [4]. This is probably one of the contributing factors as to why LRP has not been widely adopted despite the potential advantages of a minimally invasive approach [5–7]. However, it has been shown that the learning curve of LRP can be reduced with formal LRP Fellowship training [8–10]. A modular approach to training has been previously described, such as the Heilbronn and Leipzig models that allow for stepwise mentoring of LRP [11,12]. Unfortunately, most of these programmes are in high-volume centres outside © 2014 The Authors BJU International © 2014 BJU International | doi:10.1111/bju.12799 Published by John Wiley & Sons Ltd. www.bjui.org
Although other authors with larger training numbers have previously reported that the skills for LRP are transferrable safely, these studies have occurred when the primary surgeon is beyond their early learning curve [1,9,11,13]. Our present study is unique in that it investigates the initial results and safety in implementing LRP training whilst the primary surgeon is still in their initial learning curve and is also the first Australasian centre assessing LRP training.
Patients and Methods With ethics approval [Northern Sydney Coast EC0012 (NSC) Human Research Ethics Committee (HREC) 1206 212M], data was collected prospectively from the initial 207 consecutive patients who underwent LRP between September 2009 and
BJU Int 2014; 114, Supplement 1, ••–•• wileyonlinelibrary.com
Luke et al.
January 2014, immediately after a 12-month LRP Fellowship in a high-volume centre by the primary surgeon (M.L.J.). All cases were performed or supervised by the primary surgeon and all patients with localised prostate cancer who chose to have surgical treatment underwent LRP, i.e. there were no exclusions or referrals for open or robot-assisted RP regardless of obesity, prostate size and previous surgery (including prior laparoscopic hernia repairs).
Operative skin-to-skin surgical time, blood loss, length of hospital stay and complications were recorded. All pathological specimens were weighed prior to fixation in formalin and the entire gland was blocked. Gleason grading, pathological staging and positive surgical margins (PSMs) were reported in accordance with the guidelines of the International Society of Uropathologists (ISUP) and was reviewed by a senior Uropathologist (W.P.).
A five-port extraperitoneal approach was used with the operative steps and technique previously described [4,10]. Bilateral pelvic lymphadenectomy was performed in patients with D’Amico high-risk prostate cancer [14]. From case 111 the urethrovesical anastomosis was modified from an interrupted 3/0 polyglactin 910 (Vicryl™) to two continuous barbed absorbable (V-Loc™) sutures. Neurovascular bundle preservation was performed using athermal interfascial technique in patients with a Gleason score of
Objective To assess the feasibility of introducing laparoscopic radical prostatectomy (LRP) training during the primary surgeon’s early learning curve in a regional Australian centre.
Patients and methods From a prospective single surgeon database perioperative, oncological and functional outcome data was collected from the first 207 consecutive patients who underwent LRP immediately after a 12-month LRP Fellowship in a high-volume centre by the primary surgeon (M.L.J.). A training case was defined as the successful completion of at least two of 10 steps by a training Fellow. Perioperative and oncological outcomes were compared in training and non-training cohorts and overall learning curve was assessed by comparing consecutive 50-patient cohorts.
Operative times were significantly longer in training cases (mean 269 vs 209 min; P < 0.001). There was no statistically significant difference in perioperative outcomes of length of stay (2.7 vs 2.6 days), transfusion rates (3.1% vs 2.1%), major complication (Clavien >3a) rates (1.6% vs 2.1%) or positive surgical margins (PSMs: pT2 2.8% vs 15.3% and pT3 52.0% vs 45.1%) between training and non-training groups, respectively. Overall, there were two open conversions (1.0%).
Conclusion Despite the challenging learning curve, LRP training can be commenced safely with a stepwise modular approach, even when the primary surgeon is in their early learning curve. Perioperative outcomes including PSMs and major complications were unaffected by trainee involvement.
Results
Keywords
In all, 31% of cases were training cases with a median (range) of 7 (2–10) steps of 10 steps performed by the training Fellow.
laparoscopic radical prostatectomy, prostate cancer, training, learning curve
Introduction
Australasia and this is where most Australasian Fellows performing LRPs have been trained [8].
The steep learning curve of laparoscopic radical prostatectomy (LRP) is well recognised [1]. The initial experience of high-volume first generation surgeons have suggested that >200 cases may be required to overcome the learning curve for surgical margins [2,3] and up to 700 for the functional outcomes, such as potency [4]. This is probably one of the contributing factors as to why LRP has not been widely adopted despite the potential advantages of a minimally invasive approach [5–7]. However, it has been shown that the learning curve of LRP can be reduced with formal LRP Fellowship training [8–10]. A modular approach to training has been previously described, such as the Heilbronn and Leipzig models that allow for stepwise mentoring of LRP [11,12]. Unfortunately, most of these programmes are in high-volume centres outside © 2014 The Authors BJU International © 2014 BJU International | doi:10.1111/bju.12799 Published by John Wiley & Sons Ltd. www.bjui.org
Although other authors with larger training numbers have previously reported that the skills for LRP are transferrable safely, these studies have occurred when the primary surgeon is beyond their early learning curve [1,9,11,13]. Our present study is unique in that it investigates the initial results and safety in implementing LRP training whilst the primary surgeon is still in their initial learning curve and is also the first Australasian centre assessing LRP training.
Patients and Methods With ethics approval [Northern Sydney Coast EC0012 (NSC) Human Research Ethics Committee (HREC) 1206 212M], data was collected prospectively from the initial 207 consecutive patients who underwent LRP between September 2009 and
BJU Int 2014; 114, Supplement 1, ••–•• wileyonlinelibrary.com
Luke et al.
January 2014, immediately after a 12-month LRP Fellowship in a high-volume centre by the primary surgeon (M.L.J.). All cases were performed or supervised by the primary surgeon and all patients with localised prostate cancer who chose to have surgical treatment underwent LRP, i.e. there were no exclusions or referrals for open or robot-assisted RP regardless of obesity, prostate size and previous surgery (including prior laparoscopic hernia repairs).
Operative skin-to-skin surgical time, blood loss, length of hospital stay and complications were recorded. All pathological specimens were weighed prior to fixation in formalin and the entire gland was blocked. Gleason grading, pathological staging and positive surgical margins (PSMs) were reported in accordance with the guidelines of the International Society of Uropathologists (ISUP) and was reviewed by a senior Uropathologist (W.P.).
A five-port extraperitoneal approach was used with the operative steps and technique previously described [4,10]. Bilateral pelvic lymphadenectomy was performed in patients with D’Amico high-risk prostate cancer [14]. From case 111 the urethrovesical anastomosis was modified from an interrupted 3/0 polyglactin 910 (Vicryl™) to two continuous barbed absorbable (V-Loc™) sutures. Neurovascular bundle preservation was performed using athermal interfascial technique in patients with a Gleason score of
