THE "NEW" PROSTATE CANCER INFOLINK

With what seems like an extraordinarily unusual willingness to unmask the flawed process of learning a new surgical technique, Eden et al. have carefully documented a 7-year learning process as the first-named author executed his first 1,000 laparoscopic radical prostatectomies, between 2000 and 2007. Eden actually carried out 83 percent of the procedures himself, and supervised the remain 17 percent.

The article contains the usual information about levels of blood loss, types of patient, hospitalization time, and the other minutiae that one would expect. However, more importantly from a patient perspective, the article also contains a series of honest admissions that are more surprising, as follows:

• Achievement of a standard operating time and minimal blood loss required “only” about 100-150 cases, but …
• It took 150-200 cases for Eden to reach a plateau for complication and continence rates, and …
• “The longest learning curve was for potency, which did not stabilize until 700 cases” had been completed.

This was a surgeon with significant and contemporary prior experience of both open radical prostatectomy and reconstructive laparoscopy prior to carrying out his first LRP. We are not talking about a novice.

The authors draw the following conclusions:

• These learning curves are likely to be considerably shorter when surgeons are taught in departments with a high throughput of cases, but both surgeons and patients should be aware of them.
• LRP should not be “self-taught” but should be learned within an immersion teaching program.
• Even then, a large surgical volume is likely to be needed to maintain clinical outcomes at the highest level.

The implications for patients are even more striking, particularly given the widespread and recent adoption of “robotic” technology for laparoscopic surgery. What Dr. Eden and his colleagues are telling us is that any laparoscopic prostate cancer surgeon who has done less than 500 cases may still be relatively early in his or her “learning curve” and that any surgeon who is doing fewer than a couple of hundred laparoscopic prostatectomies a year may not be operating at the highest skill level.

The “New” Prostate Cancer InfoLink has said over and over again that in picking a surgeon it is imperative to get a very clear understanding of his skill level and his case load to be sure that he (or she) is actually capable of operating on you to the highest standards. It is gratifying to see our advice so clearly reflected through one individual’s experience, carefully documented in the medical literature.

In recent months there have been a number of papers suggesting that the rapid adoption of LRP and (more particularly) RALP has resulted in poorer-quality outcomes than had been seen previously with open surgery. If Eden et al. are to believed, the explanation is relatively simple: these are not easy techniques to learn to execute well!

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