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Experience certainly improves technical skill at RALP

Posted Feb 17 2011 12:00am

There has been a lot of media noise about a poster presented at the Genitourinary Cancer Symposium. The poster supposedly suggests that it takes 1,600 robot-assisted procedures (RALP) to be really good at this form of surgery. It has been extensively discussed in a report on (just as an example).

Now there is no doubt whatsoever that the more dedicated the surgeon, the greater the basic skill s/he brings to the operating room, and the more procedures s/he does, the better the outcomes will be over time. So it is hardly surprising to find that extensive experience will improve the quality of outcomes that specific surgeons can attain.

What did the study by Sooriakumaran et al. actually show?

The authors carried out a retrospective study of 3,794 patients who were given a RALP by three specific surgeons between January 2003 and September 2009. They calculated the mean overall rates of positive surgical margins (PSMs) and the mean overall surgical operating time (OT) for each of the three surgeons at intervals of 50 RALPs per surgeon.

They were able to show that:

  • Rates of  PSMs for all patients demonstrated improvements that continued with greater surgeon experience.
  • For these three surgeons, it required > 1,600 cases to get a PSM rate of < 10 percent.
  • When only pT3 patients were evaluated, the learning curve started to plateau after 1,000-1,500 cases.
  • Mean OT plateaued after 750 cases but started to rise again with further surgical experience.

The authors conclude only that the learning curve for RALP is not as short as previously thought, and that a large number of cases are needed to get PSM rates and OTs to a minimum. They further point out the obvious corrollary that RALP should be performed by high volume surgeons in order to optimize patient outcomes.

The “New” Prostate Cancer InfoLink would point out, however, that there are other data suggesting that some surgeons have a very low incidence of PSMs with a much lower degree of experience. Are these surgeons naturally more skilled? Do they have better eyesight that allows them to better identify potentially cancerous tissue?

We have no idea how many surgeons have actually carried out > 1,600 RALPs, but it can’t be very many. We would also point out that speed is not necessarily a good quality when it comes to carrying out RALPs. It is interesting that, as these three surgeons carried out more operations, they actually realized that they needed to slow down in order to get the highest quality outcomes.

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