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.