Fast track — ArticlesThe surgical learning curve for laparoscopic radical prostatectomy: a retrospective cohort study
Introduction
Surgical procedures are often highly complex, and it is reasonable to suppose that a surgeon must build experience with a procedure before being able to do it optimally. As such, the learning curve is a ubiquitous concept among surgeons. However, most studies of surgical learning curves have focused on improvements in technical aspects, such as operating time1 and blood loss.2 Such endpoints are less relevant to patients than those related to the reason for their operation, such as relief of symptoms, improvement of function, or cure of cancer.
Previously, we analysed data from 7765 patients treated with open radical prostatectomy to calculate a learning curve for surgical efficacy, defined in terms of prostate-cancer recurrence. The probability of recurrence initially dropped steeply then reached a plateau once a surgeon had done about 250–350 operations.3 We subsequently reported that the learning curve for organ-confined cancer approached a zero recurrence rate for the most experienced surgeons (1500 or more operations).4 This suggests that cancer recurrence in patients treated with open radical prostatectomy is largely the result of limitations in surgical technique, and that the plateau in our original report was driven by disseminated disease in locally advanced cancer.4
In the present study we report the learning curve for laparoscopic radical prostatectomy. This serves as a replication study on an independent (and international) cohort, and enables us to make comparisons between open and laparoscopic learning curves.
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Patients
Previously, we established a multicentre, international retrospective cohort of patients treated by laparoscopic radical prostatectomy, without robotic assistance.5 Seven participating institutions (Cleveland Clinic Foundation, USA; Institut Mutualiste Montsouris, France; Memorial Sloan-Kettering Cancer Center, USA; Hospital Universitario La Paz, Spain; Klinikum Heibronn, Germany; Lahey Clinic, USA; and Krankenhaus der Elisabethinen, Austria) provided recurrence data for a cohort of 5328
Results
The distribution of surgeons by the total number of lifetime operations is shown in table 1. Although many of the surgeons had done fewer than 50 laparoscopic radical prostatectomies (the fewest number performed was two), around half had done more than 100 procedures, with a maximum experience of 1066 procedures. Clinical and pathological information of patients is shown in table 2, stratified by surgeon experience. 30% of patients (1404 of 4702) were seen by a surgeon who had done less than
Discussion
The probability of recurrence after laparoscopic radical prostatectomy decreases as the experience of the operating surgeon increases. In addition to replicating the radical prostatectomy learning curve on an independent dataset, our data enable us to compare learning curves between open and laparoscopic surgical approaches. Surgical outcome seems to improve more slowly for laparoscopic than for open surgery.
There are several possible explanations for this observation. First, laparoscopic
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