title: Developing a robotic prostatectomy service and a robotic fellowship programme - defining the learning curve.
abstract: BACKGROUND
  Robotic radical prostatectomy (RRP) is an established treatment for prostate cancer in selected centres with appropriate expertise. We studied our single-centre experience of developing a RRP service and subsequent training of 2 additional surgeons by the initial surgeon and the introduction of United Kingdom's first nationally accredited robotic fellowship training programme. We assessed the learning curve of the 3 surgeons with regard to peri-operative outcomes and oncological results.
  
  
  METHODS
  Three hundred consecutive patients underwent RRP between November 2008 and August 2012. Patients were divided into 3 equal groups (Group 1, case 1-100; Group 2, case 101-200; and Group 3, case 201-300). Age, ASA score, preoperative co-morbidities and indications for laparoscopic radical prostatectomy were comparable for all 3 patient groups. Peri-operative and oncological outcomes were compared across all 3 groups to assess the impact of the learning curve for laparoscopic radical prostatectomy. All surgical complications were classified using the Clavien-Dindo system.
  
  
  RESULTS
  The mean age was 60.7 years (range 41-74). There was a significant reduction in the mean console time (p < 0.001), operating time (p < 0.001), mean length of hospital stay (p < 0.001) and duration of catheter (p < 0.001) between the 3 groups as the series progressed. The two most important factors predictive of positive surgical margins (PSM) at RRP were the initial prostate specific antigen (PSA) and tumor stage at diagnosis. The overall PSM rate was 26.7%. For T2/T3 tumors the incidence of PSM reduced as the series progressed (Group 1-22%, Group 2-32% and Group 3-26%). The incidence of major complications i.e. grade Clavien-Dindo system score ≤ III was 2% (6/300).
  
  
  CONCLUSIONS
  RRP is a safe procedure with low morbidity. As surgeons progress through the learning curve peri-operative parameters and oncological outcomes improve. This learning curve is not affected by the introduction of a fellowship-training programme. Using a carefully structured mentored approach, RRP can be safely introduced as a new procedure without compromising patient outcomes.
authors.affiliation: Department of UrologyAnaesthetics, Hertfordshire and South Bedfordshire Urological Cancer Centre, Lister Hospital, Stevenage, UK.
authors.forename: Nikhil
authors.initials: N
authors.lastname: Vasdev
authors.affiliation: Department of UrologyAnaesthetics, Hertfordshire and South Bedfordshire Urological Cancer Centre, Lister Hospital, Stevenage, UK.
authors.forename: Conrad
authors.initials: C
authors.lastname: Bishop
authors.affiliation: Department of UrologyAnaesthetics, Hertfordshire and South Bedfordshire Urological Cancer Centre, Lister Hospital, Stevenage, UK.
authors.forename: Atoine
authors.initials: A
authors.lastname: Kass-Iliyya
authors.affiliation: Anaesthetics, Hertfordshire and South Bedfordshire Urological Cancer Centre, Lister Hospital, Stevenage, UK.
authors.forename: Sami
authors.initials: S
authors.lastname: Hamid
authors.affiliation: Department of UrologyAnaesthetics, Hertfordshire and South Bedfordshire Urological Cancer Centre, Lister Hospital, Stevenage, UK.
authors.forename: Thomas A
authors.initials: TA
authors.lastname: McNicholas
authors.affiliation: Anaesthetics, Hertfordshire and South Bedfordshire Urological Cancer Centre, Lister Hospital, Stevenage, UK.
authors.forename: Venkat
authors.initials: V
authors.lastname: Prasad
authors.affiliation: Anaesthetics, Hertfordshire and South Bedfordshire Urological Cancer Centre, Lister Hospital, Stevenage, UK.
authors.forename: Gowrie
authors.initials: G
authors.lastname: Mohan-S
authors.affiliation: Department of UrologyAnaesthetics, Hertfordshire and South Bedfordshire Urological Cancer Centre, Lister Hospital, Stevenage, UK.
authors.forename: Timothy
authors.initials: T
authors.lastname: Lane
authors.affiliation: Department of UrologyAnaesthetics, Hertfordshire and South Bedfordshire Urological Cancer Centre, Lister Hospital, Stevenage, UK.
authors.forename: Gregory
authors.initials: G
authors.lastname: Boustead
authors.affiliation: Department of UrologyAnaesthetics, Hertfordshire and South Bedfordshire Urological Cancer Centre, Lister Hospital, Stevenage, UK.
authors.forename: James M
authors.initials: JM
authors.lastname: Adshead
keywords: Fellowship training; Learning curve; Prostate cancer; Robotic radical prostatectomy