Editorial Comment from Dr Shiroki to Comparative investigation on clinical outcomes of robot-assisted radical prostatectomy between experienced open prostatic surgeons and novice open surgeons in a laparoscopically naïve center with a limited caseload.

Abstract

Robotic surgery has been rapidly adopted in Japan since 2012, when robot-assisted radical prostatectomy (RARP) was approved for government insurance coverage.1 It is a very unique situation in the world, because once robots are installed in certain hospitals, almost no open prostatectomies (ORP) are carried out there. Under such circumstances, surgical education for young urologists is very important, so they become established robotic surgeons even with limited open surgery experience. From their retrospective analysis of RARP, Sumitomo et al. described that their own series of RARP offered satisfactory peri- and postoperative outcomes even for surgeons with little or no ORP experience under an experienced mentor's supervision.2 They also pointed out the need for more training and experience for novice ORP surgeons, so they can overcome the learning curve on their first series of RARP cases. I believe this is a very important study, as it shows the feasibility of surgeons without ORP experience to adopt RARP safely. I want to congratulate the authors’ effort to establish an education program to teach robotic surgery. The authors also introduced their practical mentoring methods. We can understand real mentor-led surgery following the concept of parallel learning on their initial phase of the procedure. The authors focused on the importance of providing the initial experience of RARP for several surgeons with or without ORP experience rather than a learning curve for clinical end-points. Davis et al. showed experienced volume of surgery affected the learning curve. Experience of open surgery did not affect the outcome during the learning curve.3 Farivar et al. showed a poor educational program for robotic surgery for residents then in the USA.4 Although approximately 64% of residents reported that formal training in robotic surgery was important in training, 60% of them reported no prior education or training before their first robotic case. An academic institution in Japan showed that a constitutional learning program provided a safe and educational procedure.1 In the near future, the majority of young urologists will become robotic surgeons without enough experience of open surgery. Under such circumstances, the Japanese Urological Association and the Japanese Society of Endourology have established the proctor control system to supervise safe surgery for novice robotic surgeons. Proctors will be qualified by a listed program committee according to their robotic surgery experience. This established system is thought to be the first proctoring program authorized by a nationwide academic society in the world. We are still planning to improve this proctoring program with practical feedback for the future. Finally, after reading this study, I remember the time I learned transurethral resection of the prostate from my mentor during residency. He was a skillful and talented surgeon, and said to me “You might as well learn open prostatectomy for benign prostatic hyperplasia surgery, but maybe you do not have to anymore.” So, I want to say, “Time goes on. History repeats itself.” None declared.