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