The learning curve of robot-assisted radical cystectomy: results from the International Robotic Cystectomy Consortium.
BACKGROUND
Robot-assisted radical cystectomy (RARC) has evolved as a minimally invasive alternative to open radical cystectomy for patients with invasive bladder cancer.


OBJECTIVE
We sought to define the learning curve for RARC by evaluating results from a multicenter, contemporary, consecutive series of patients who underwent this procedure.


METHODS
Utilizing the International Robotic Cystectomy Consortium database, a prospectively maintained and institutional review board-approved database, we identified 496 patients who underwent RARC by 21 surgeons at 14 institutions from 2003 to 2009.


METHODS
Cut-off points for operative time, lymph node yield (LNY), estimated blood loss (EBL), and margin positivity were identified. Using specifically designed statistical mixed models, we were able to inversely predict the number of patients required for an institution to reach the predetermined cut-off points.


CONCLUSIONS
Mean operative time was 386 min, mean EBL was 408 ml, and mean LNY was 18. Overall, 34 of 482 patients (7%) had a positive surgical margin (PSM). Using statistical models, it was estimated that 21 patients were required for operative time to reach 6.5h and 8, 20, and 30 patients were required to reach an LNY of 12, 16, and 20, respectively. For all patients, PSM rates of <5% were achieved after 30 patients. For patients with pathologic stage higher than T2, PSM rates of <15% were achieved after 24 patients.


CONCLUSIONS
RARC is a challenging procedure but is a technique that is reproducible throughout multiple centers. This report helps to define the learning curve for RARC and demonstrates an acceptable level of proficiency by the 30th case for proxy measures of RARC quality.
Hayn
Matthew H
MH
Department of Urologic Oncology, Roswell Park Cancer Institute, Elm and Carlton Streets, Buffalo, NY 14263, USA.
Hussain
Abid
A
Mansour
Ahmed M
AM
Andrews
Paul E
PE
Carpentier
Paul
P
Castle
Erik
E
Dasgupta
Prokar
P
Rimington
Peter
P
Thomas
Raju
R
Khan
Shamim
S
Kibel
Adam
A
Kim
Hyung
H
Manoharan
Murugesan
M
Menon
Mani
M
Mottrie
Alex
A
Ornstein
David
D
Peabody
James
J
Pruthi
Raj
R
Palou Redorta
Joan
J
Richstone
Lee
L
Schanne
Francis
F
Stricker
Hans
H
Wiklund
Peter
P
Chandrasekhar
Rameela
R
Wilding
Greg E
GE
Guru
Khurshid A
KA
D000368:Aged; D015653:Cystectomy / Q000379:methods*; D005260:Female; D006801:Humans; D059032:Learning Curve; D008297:Male; D009361:Neoplasm Invasiveness; D012371:Robotics; D001749:Urinary Bladder Neoplasms / Q000473:pathology / Q000601:surgery*