Strengths and Limitations
Our study has several strengths. First, all procedures were performed by
one surgical team in a high-volume tertiary cancer centre service, which
resulted in a large cohort with highly comparable surgical
circumstances. Moreover, all consultants providing training completed
the same LAPCO ‘Train the Trainers’ course.25 Thereby,
the manner of PBP training was similar in all training cases. Secondly,
we trained 18 gynaecological oncology trainees in RAL surgery for
endometrial cancer in a PBP manner. Consequently, our results represent
a more general effect of PBP training in RAL surgery for endometrial
cancer on peri-operative and survival outcomes than previous studies,
that only assessed one trainee.26,27
Thirdly, our data was mainly collected prospectively which reduced the
chance of information bias and resulted in a limited amount of missing
data. One independent researcher completed the database retrospectively
thereby further reducing the likelihood of information bias.
Our study also has some limitations. The main limitation of our study is
that we did not record which part of the surgery was performed by the
trainee. In PBP training trainees gradually build their contribution to
the surgery, starting with vault suturing and ending with independent
performance of hysterectomy, bilateral salpingo-oophorectomy and lymph
node dissection. With our data we were unable to define the effect of
performance of a specific part of the surgery by a trainee on
peri-operative and survival outcomes. Thereby, we possibly underestimate
the effect of training in individual steps of RAL surgery on our
outcomes. On the other hand, our results highlight a real-world training
environment and show some expected differences between training and
non-training cases (lower BMI and longer operating time) suggesting that
our study had the distinguishing capacities needed to pick up major
differences between training and non-training cases. Our future aim is
to further investigate the influence of distinct parts of RAL surgery
performed by a trainee on peri-operative and survival outcomes.
Furthermore, compared to other robotic cohorts28-30 we
have a high percentage of high grade tumours (44.9%) and high stage
disease (31.1%) which is related to the tertiary referral status of our
department. This might limit the generalisability of our results. Direct
comparison with other robotic cohorts is needed to further evaluate the
effect of PBP training on peri-operative and survival outcomes for RAL
surgery in all stages of endometrial cancer.