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.