The learning curve for laparoscopic radical prostatectomy: an international multicenter study.
OBJECTIVE
It is not yet possible to estimate the number of cases required for a beginner to become expert in laparoscopic radical prostatectomy. We estimated the learning curve of laparoscopic radical prostatectomy for positive surgical margins compared to a published learning curve for open radical prostatectomy.


METHODS
We reviewed records from 8,544 consecutive patients with prostate cancer treated laparoscopically by 51 surgeons at 14 academic institutions in Europe and the United States. The probability of a positive surgical margin was calculated as a function of surgeon experience with adjustment for pathological stage, Gleason score and prostate specific antigen. A second model incorporated prior experience with open radical prostatectomy and surgeon generation.


RESULTS
Positive surgical margins occurred in 1,862 patients (22%). There was an apparent improvement in surgical margin rates up to a plateau at 200 to 250 surgeries. Changes in margin rates once this plateau was reached were relatively minimal relative to the CIs. The absolute risk difference for 10 vs 250 prior surgeries was 4.8% (95% CI 1.5, 8.5). Neither surgeon generation nor prior open radical prostatectomy experience was statistically significant when added to the model. The rate of decrease in positive surgical margins was more rapid in the open vs laparoscopic learning curve.


CONCLUSIONS
The learning curve for surgical margins after laparoscopic radical prostatectomy plateaus at approximately 200 to 250 cases. Prior open experience and surgeon generation do not improve the margin rate, suggesting that the rate is primarily a function of specifically laparoscopic training and experience.
Department of Urology, Memorial Sloan-Kettering Cancer Center, New York, New York 10021, USA.
Fernando P
FP
Secin
Caroline
C
Savage
Claude
C
Abbou
Alexandre
A
de La Taille
Laurent
L
Salomon
Jens
J
Rassweiler
Marcel
M
Hruza
François
F
Rozet
Xavier
X
Cathelineau
Gunther
G
Janetschek
Faissal
F
Nassar
Ingolf
I
Turk
Alex J
AJ
Vanni
Inderbir S
IS
Gill
Philippe
P
Koenig
Jihad H
JH
Kaouk
Luis
L
Martinez Pineiro
Vito
V
Pansadoro
Paolo
P
Emiliozzi
Anders
A
Bjartell
Thomas
T
Jiborn
Christopher
C
Eden
Andrew J
AJ
Richards
Roland
R
Van Velthoven
Jens-Uwe
JU
Stolzenburg
Robert
R
Rabenalt
Li-Ming
LM
Su
Christian P
CP
Pavlovich
Adam W
AW
Levinson
Karim A
KA
Touijer
Andrew
A
Vickers
Bertrand
B
Guillonneau
D000368:Aged; D006801:Humans; D010535:Laparoscopy / Q000193:education* / Q000706:statistics & numerical data; D059032:Learning Curve; D008297:Male; D008875:Middle Aged; D011468:Prostatectomy / Q000193:education* / Q000379:methods* / Q000706:statistics & numerical data; D011471:Prostatic Neoplasms / Q000601:surgery*