Main findings
This is the first study, using RA-CUSUM analysis, to evaluate the length
of the learning period of robot-assisted laparoscopy on oncological
outcomes. Our results suggest an institutional learning phase of at
least 61 procedures, showing a decreasing recurrence rate with
increasing experience. The 5-year DFS and DSS significantly improved in
patients treated after this initial learning phase. The 5-year DFS and
OS in our cohort are comparable with other recent studies on
robot-assisted surgery in the treatment of cervical
cancer6,8,14 and moreover, similar to the national
recurrence and survival rates for early stage cervical cancer in The
Netherlands.29 When regarding the 4.5-year DFS, the
outcome parameter provided in the Laparoscopic Approach in Cervical
Cancer (LACC) trial, we found that 93% of the patients treated during
the experienced phase (group 2) were free of recurrence at 4.5 years of
follow-up. This is substantially higher than the 4.5-year DFS of 86%
reported in the MIS arm of the LACC trial.9Unfortunately, the exact MIS volume and (RA-CUSUM based) individual
learning curves are unknown for the inclusion centres of the LACC trial.
Furthermore, their surgical proficiency assurance was limited to
providing data from (a minimum of) any 10 laparoscopic surgeries and two
procedural videos, which in light of our main findings could be
considered insufficient.