More on the surgical learning curve for LRP

A study to appear in Lancet Oncology has reported information on the surgical learning curve associated with (non-robotic) laparoscopic radical prostatectomy (LRP). The study appears to confirm prior reports that LRP is a difficult technique to learn to do well.

Vickers et al. conducted a retrospective cohort study of 4,702 patients with prostate cancer treated laparoscopically by one of 29 surgeons from seven institutions in Europe and North America between January 1998 and June 2007.

Including relevant adjustments for case mix, the results of this study may be summarized as follows:

  • Greater surgeon experience was associated with a significant lower risk of recurrence (p=0·0053).
  • The 5-year risk of recurrence decreased from 17 to 16 to 9 percent for a patient treated by a surgeon who had completed 10, 250, and 750 prior LRPs, respectively.
  • The learning curve for LRP is slower than the previously reported learning curve for open surgery (p<0·001).
  • Surgeons with previous experience of open radical prostatectomy had significantly poorer results than those whose first operation was laparoscopic.

The authors interpret these results to indicate that, “Increasing surgical experience is associated with substantial reductions in cancer recurrence after laparoscopic radical prostatectomy, but improvements in outcome seem to accrue more slowly than for open surgery.” They also suggest that, “Laparoscopic radical prostatectomy seems to involve skills that do not translate well from open radical prostatectomy.”

These data appear to correlate well with a prior individual report by Eden and colleagues on his own surgical learning experience. However, it may be reasonable to bear in mind that the small group of surgeons who were first to carry out this technique regularly in the late 1990s were “flying by the seats of their pants,” and had no highly experienced mentors to learn from.

Dr. Vickers is a member of the Scientific Advisory Board of The “New” Prostate Cancer InfoLink.

2 Responses

  1. I just wrote about this story on my blog. I guess you have to get yourself a VIRGIN surgeon (never done RRP) who is also an artiste — done 750 RALPs. Don’t know anyone who fits the bill.

    Can you explain what this means?

    “… but improvements in outcome seem to accrue more slowly than for open surgery.”

  2. Leah: It is very important in reading this paper to discriminate between LRP and RALP. This study only compares LRP to open surgery. It did not include any surgeons using RALP.

    There might be a small number of surgeons in Europe by now who had learned to do LRPs without ever doing an RRP — so there might be a few virgins, but not too many! In American today, 95 percent of trainees are learning to do RALPs, so there are probably no virgins of the LRP persuasion in America. In Europe RALP is still rare because of the cost of the robot, and many trainees will learn to do LRPs.

    With respect to your question … “… but improvements in outcome seem to accrue more slowly than for open surgery” means that better overall outcomes were evident after fewer procedures (on average) among surgeons learning RRP as compared to surgeons learning LRP.

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