1786 TIME TO ONCOLOGIC PROFICIENCY IN ROBOTIC RADICAL PROSTATECTOMY: SUCCESSFULLY REDUCING THE LEARNING CURVE IN A MULTI-SURGEON PROGRAM

Abstract

INTRODUCTION AND OBJECTIVES: In the last 5 years Robotic–assisted Radical Prostatectomy (RALP) has rapidly become the primary form of surgical treatment for radical prostatectomy (RP). Multiple studies have documented a significant learning curve for RALP, even for experienced open or laparoscopic surgeons. Our objective was to develop a multi-surgeon robotic surgery program that would allow all surgeons learning RALP to achieve proficiency (as measured by surgical margin status), without compromising “cancer control” during the learning curve. METHODS: The robotic surgery program for Southern California Kaiser Permanente started August, 2008. The program began with 10 surgeons, all with prior experience in laparoscopic RP ( 50 cases). In addition, three of the surgeons had completed an accredited fellowship in robotic surgery, and had prior experience in performing RALP. These surgeons served as preceptors for the other surgeons. Surgery was undertaken in a step-wise fashion, with all surgeons completing 10 cases with the preceptor. Subsequently, each RALP that was performed was done so with one of the original 10 surgeons serving as primary assistant. Since the inception of the program, 8 additional surgeons have been trained. We prospectively collected pathologic data, using margin status as a surrogate endpoint for cancer control. RESULTS: As of October, 2010, 1232 RALPs have been performed. Mean patient age is 59.3. Mean pre-operative PSA level is 7.2 (0.6–41). Mean Gleason’s score was 6.3 (5–10). All prostate specimens were reviewed by the same 3 pathologists at one institution. 962 (78%) patients were pathologic stage pT2 and 270 (22%) of patients were pT3. The mean number of cases performed per surgeon is 79 (4–147). Surgical margin status was evaluated for the first 1200 cases by quartile (1st 300 cases, 2nd 300, 3rd 300 and 4th 300) and is as follows: For pT2: 24%, 14%, 13% and 11%; for pT3: 51%, 43, 21 and 25%, respectively per quartile. Total Major complication rate (Clavien grade 3 and 4): 1.3%. CONCLUSIONS: While it is premature for us to use biochemical recurrence to evaluate surgical proficiency, surgical margin status remains a primary surrogate endpoint to assess surgical technique and to provide feedback to surgeons along the “learning curve.” We have demonstrated that an acceptable positive surgical margin status for RALP, as well as a low complication rate, can be achieved within a relatively short period of time, using a standardized preceptorship program. We are currently using this same format to train surgeons for additional robotic procedures.