Population and procedure
This article is an expansion of our previous publication where we performed an observational cohort study to assess the initial learning curve of robot-assisted surgery for early-stage cervical cancer. There, we demonstrated a learning phase of at least 61 procedures (of a single surgical team) with significant negative impact on the oncological outcomes of cervical cancer patients.8
In April 2017, after 165 procedures performed by a single surgical team (surgeon A + B), a novice robotic surgeon (surgeon C) was introduced, replacing one of the experienced surgeons. The newly introduced surgeon, who had previous experience with conventional laparoscopy, was trained in accordance with the structured and stepwise robotic training of the SERGS learning curriculum24, including simulation and cadaver training, before he started in real-life patient setting under supervision of a proctor (surgeon B) in April 2017. The first 61 consecutive cases performed by this new surgical team (surgeon B + C) were added to our cohort, resulting in an updated total cohort of 226 cervical cancer patients treated between December 2007 and August 2019: the learning phase of 61 procedures (group 1), the experienced phase of 104 procedures thereafter (group 2), and the 61 consecutive procedures during introduction of a novice (group 3).
The same inclusion criteria were applied: patients diagnosed with FIGO 2009 stage IA1 (with lymph-vascular space invasion (LVSI)) up to IB1 or IIA1 cervical cancer who were consecutively treated with primary robot-assisted laparoscopy.25, 26 The FIGO 2009 edition was used as reference because a majority of cases were staged according to this FIGO edition. Excluded were patients with ongoing pregnancy or who were treated with neoadjuvant chemotherapy (EORTC 55994).
All robot-assisted procedures were performed at our tertiary referral centre using the da Vinci Surgical System (Intuitive Surgical, Sunnyvale, CA, USA, type S until 2010, Si until 2018, and X or Xi since 2018 onwards). During the inclusion period, robot-assisted surgery was the standard of care, with laparotomy only performed incidentally for those who had an absolute contraindication (e.g. advanced pregnancy). All details on surgical technique, data collection, and statistical analysis were described previously.8