Authors
Ilse G.T. Baetena, Jacob P.
Hoogendama, Henk W.R. Schreudera,
Ina M. Jürgenliemk-Schulzb, Cornelis G.
Geresteina, Ronald P. Zweemera
a Department of Gynaecological Oncology, Division of
Imaging and Oncology, University Medical Center Utrecht, Utrecht
University, Utrecht, the Netherlands
b Department of Radiology and Nuclear Medicine,
Division of Imaging and Oncology, University Medical Center Utrecht,
Utrecht University, Utrecht, the Netherlands
Corresponding author: Ilse G.T. Baeten, MD, Department of
Gynaecological Oncology, Division of Imaging and Oncology, University
Medical Center Utrecht, PO Box 85500, Utrecht 3508 GA, The Netherlands.
Email: i.g.t.baeten@umcutrecht.nl
Running title: Learning curve of robot-assisted gynaecological
surgery
Abstract
Objective Effect on patient outcomes when introducing a novice
robotic surgeon, trained in accordance with a structured learning
curriculum, to an experienced robotic surgery team.
Design Observational cohort study.
Setting Tertiary referral centre.
Population Patients with early-stage cervical cancer who were
treated with primary robot-assisted surgery between 2007 and 2019. In
addition to the 165 patients included in a former analysis, we included
a further 61 consecutively treated patients and divided all patients
over three groups: early learning phase of 61 procedures (group 1),
experienced phase of the 104 procedures thereafter (group 2), and the
final 61 procedures during introduction of a novice with structured
training (group 3).
Methods Risk-adjusted cumulative sum (RA-CUSUM) analysis was
performed and patient outcomes between groups were compared.
Main Outcome Measures Surgical proficiency based on recurrence,
surgical and oncological outcomes.Results Based on RA-CUSUM analysis, no learning curve effect
was observed for group 3. Regarding surgical outcomes, mean operation
time in group 3 was significantly shorter than group 1
(p <0.001) and similar to group 2 (p =0.96).
Proportions of intraoperative and postoperative adverse events in group
3 were not significantly different from the experienced group (group 2).
Regarding oncological outcomes, the 5-year disease-free survival,
disease-specific survival, and overall survival in group 3 were not
significantly different from the experienced group.
Conclusions Introducing a novice robotic surgeon, who was
trained in accordance with a structured learning curriculum, resulted in
similar patient outcomes as by experienced surgeons suggesting novices
can progress through a learning phase without compromising outcomes of
cervical cancer patients.
Keywords Cervical cancer; robot-assisted surgery; learning
curve; cumulative sum analysis
Introduction
Learning curve effects seem unavoidable when adopting new and complex
surgical technologies.1, 2 This appeared to be no
different when robot-assisted surgery was adopted for gynaecological
oncology two decades ago.3 Since then, several studies
in the gynaecological oncology field reported on short-term surgical
outcomes of robot-assisted surgery during the learning curve, e.g.
operation time or blood loss. Until recently, learning curve effect on
long-term outcomes, such as survival, were often
omitted.4-7 Multiple studies on robot-assisted surgery
for cervical cancer showed worse survival outcomes in early stages of
the learning curve versus after mastery.8-12 This
learning curve effect could be one of the explanations for the results
of recent retrospective and prospective studies reporting inferior
survival of cervical cancer patients treated with minimally invasive
surgery compared to open surgery.13, 14 These results
underscored the need for structured and validated learning curricula
intended to improve quality of care when introducing surgeons to a new
technology, while minimizing learning curve effects and patient
harm.15
Since the adoption of the surgical robot by gynaecologists, the learning
environment has evolved. Training modalities like virtual reality
simulation, cadaver training, proctoring and use of dual consoles
emerged and showed to be effective in acquiring robotic
skills.16-20 In the past years, these training
modalities have been brought together into several structured learning
curricula for robot-assisted gynaecological surgery, such as the Society
of European Robotic Gynaecological Surgery (SERGS)
curriculum.21 A prospectively validated curriculum is,
however, still lacking.22 While training modalities
keep evolving and qualitative research shows that fellows experience
increased confidence when having access to these modalities, little is
known about how existing curricula are performing in terms of actual
skill acquisition, and how the acquired robotic skills translate into
patient outcomes.22, 23
The aim of our study was to assess the learning curve of robot-assisted
surgery for early-stage cervical cancer when introducing a novice
robotic surgeon to an experienced surgical team and assess the effect on
patient outcomes. Previously, we demonstrated a single-institutional
learning curve required at least 61 procedures before levelling out when
initially starting with robot-assisted surgery.8 By
expanding our cohort with 61 consecutively treated cases during
introduction of a novice, who was trained in accordance with a
structured learning curriculum, we evaluated whether the learning curve
of this novice surgeon impacted surgical and oncological outcomes of
early-stage cervical cancer patients.
Methods