Interpretation
To date no other studies have evaluated the general effect of PBP training in RAL surgery for endometrial cancer on peri-operative and survival outcomes. However, a learning curve for RAL surgery in endometrial cancer has previously been assessed.26.27By comparing peri-operative outcomes between cases performed in the early stages of the learning curve and cases performed in later stages of the learning curve, we can roughly compare these results with our training and non-training cases. However, it must be noted that these studies were performed by single surgeons and only assessed a limited number of peri-operative outcomes. One study26observed a significant decreasing EBL between cases performed early in the learning curve and later cases, which was not observed in our cohort. However, our results on operating time are in line with two other studies26,27, who found significant improvements in operating time between cases performed in early stages of the learning curve and later cases.
No studies assessing the learning curve of RAL surgery for endometrial cancer evaluated survival outcomes. However, Baeten et al11 assessed 5-year disease-free and disease-specific survival for cervical cancer patients undergoing RAL surgery and found significantly worse outcomes for cases in the early stages of the learning curve compared to cases in later stages. Comparable results were found by two more studies.13,14 We did not find such a trend in our cohort, which might be due to several differences compared to our study. First, whereas the previously mentioned studies11,13,14 analysed cases between 2007 and 2018 when there was no set training curriculum, we analysed cases between 2015 and 2022 in which timeframe PBP training was developed and implemented. Secondly, we did not look into individual learning curves as Baeten et al did but investigated the overall effect of PBP training in a tertiary cancer service on survival outcomes, which renders the possibility of underestimation of our survival outcomes (see limitations). Lastly, the effects of training in RAL surgery might differ between cervical and endometrial cancer.
Due to limited studies of RAL surgery in gynaecological oncology, we have to look at other fields of robotic surgery to compare our results. The implementation of a training curriculum for robotic-assisted radical cystectomy by the European Association of Urologists (EAU) Robotic Urology Section (ERUS) was recently evaluated.31 As in our cohort, operating time was significantly longer in training cases, but otherwise the trainee showed non-inferiority compared to the experienced surgeon in terms of EBL, positive soft tissue margins, number of resected lymph nodes, overall and high-grade complications, and 90-day readmissions. This suggests safety and efficiency of a PBP training curriculum in robotic prostatectomy.