Introduction
In the last two decades, the use of minimally-invasive surgery for
endometrial cancer has become widespread since the Laparoscopic Approach
to Cancer of the Endometrium (LACE) trial and Gynecologic Oncology Group
(GOG) LAP2 study established non-inferiority of laparoscopic versus
laparotomic surgery for disease-free and overall survival in endometrial
cancer.1-3 Robot-assisted laparoscopic (RAL) surgery
was introduced in gynaecological surgery in 20054 and
may provide more precision, better views, reduced patient morbidity and
improved surgeon ergonomics compared to conventional
laparoscopy.5-8 These advantages are especially
beneficial in obese patients undergoing open or laparoscopic
hysterectomy as they are more prone to post-operative morbidity compared
to non-obese patients.9 Obesity is the main risk
factor for endometrial cancer and since its incidence is
rising10, the preferred approach in minimally-invasive
surgery has shifted from straight-stick to robotic.
Over the last years an increased number of gynaecological oncology
surgical fellowship programs have adopted RAL surgery as part of their
training. The introduction of a new surgical technique is accompanied
with a learning curve, which has been assessed in conventional
laparoscopic and robotic surgery11-14 and underpins
the need for training curricula and guidelines.
Urologists were the first to assess the effect of training in robotic
surgery on peri-operative outcomes and developed proficiency-based
progression (PBP) training curricula for robotic
surgery.15 The Society of European Robotic
Gynaecological Surgery (SERGS) and British & Irish Association of
Robotic Gynaecological Surgeons (BIARGS) followed by providing curricula
and guidelines for training in robot-assisted gynaecological
surgery.16,17 However, the effect of training on
peri-operative and survival outcomes in endometrial cancer patients
undergoing RAL surgery has not been assessed.
The Royal Marsden Hospital is a tertiary cancer centre in the United
Kingdom (UK) treating high-risk endometrial cancer patients as a part of
the Southwest Thames Gynaecological Cancer Centre. It was the first
centre in the UK to adopt RAL surgery for gynaecological cancer in 2007
and has been training subspecialty trainees in gynaecological oncology
in RAL surgery since 2015 in a PBP training manner.
The objective of this study was to compare peri-operative and survival
outcomes for PBP-training versus non-training cases in endometrial
cancer patients undergoing RAL surgery.
MethodsThis project has received ethical approval from the ethics committee in
our centre (see Details of Ethics Approval Section). There was no public
involvement.