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.
Secin
Fernando P
FP
Department of Urology, Memorial Sloan-Kettering Cancer Center, New York, New York 10021, USA.
Savage
Caroline
C
Abbou
Claude
C
de La Taille
Alexandre
A
Salomon
Laurent
L
Rassweiler
Jens
J
Hruza
Marcel
M
Rozet
François
F
Cathelineau
Xavier
X
Janetschek
Gunther
G
Nassar
Faissal
F
Turk
Ingolf
I
Vanni
Alex J
AJ
Gill
Inderbir S
IS
Koenig
Philippe
P
Kaouk
Jihad H
JH
Martinez Pineiro
Luis
L
Pansadoro
Vito
V
Emiliozzi
Paolo
P
Bjartell
Anders
A
Jiborn
Thomas
T
Eden
Christopher
C
Richards
Andrew J
AJ
Van Velthoven
Roland
R
Stolzenburg
Jens-Uwe
JU
Rabenalt
Robert
R
Su
Li-Ming
LM
Pavlovich
Christian P
CP
Levinson
Adam W
AW
Touijer
Karim A
KA
Vickers
Andrew
A
Guillonneau
Bertrand
B
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*