Structured and Modular Training Pathway for Robot-assisted Radical Prostatectomy (RARP): Validation of the RARP Assessment Score and Learning Curve Assessment

Lovegrove, Catherine; Novara, Giacomo; Mottrie, Alexandre; Guru, Khurshid A.; Brown, Matthew; Challacombe, Benjamin; Popert, R.; Raza, Johar; Poel, Henk van der; Peabody, James O.; Dasgupta, Prokar; Ahmed, Kamran

doi:10.1016/j.eururo.2015.10.048

Cited by 91 publications

(51 citation statements)

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“…In keeping with this, Lovegrove et al have validated a RARP Assessment Score to assess competency at high-risk steps of RARP. 19 The RARP Assessment Score divides the procedure into 41 steps, which are then rated by a mentor on each case from 0 to 5. These authors did demonstrate a learning curve in multiple steps and found that the study participants rated the assessment tool acceptable, feasible, and having educational impact.…”

Section: Discussionmentioning

confidence: 99%

Positive surgical margin rates during the robot-assisted laparoscopic radical prostatectomy learning curve of an experienced laparoscopic surgeon

Adili

Giovanni

Kolesar

et al. 2017

CUAJ

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Introduction: Since its introduction, robot-assisted laparoscopic radical prostatectomy (RARP) has gained widespread popularity, but is associated with a variable learning curve. Herein, we report the positive surgical margin (PSM) rates during the RARP learning curve of a single surgeon with significant previous laparoscopic radical prostatectomy (LRP) experience. Methods: We performed a prospective cohort study of the first 400 men with prostate cancer treated with RARP by a single surgeon (BS) with significant LRP experience. Our primary outcome was the impact of case timing in the learning curve on margin status. Our analysis was conducted by dividing the case numbers into quartiles (Q1-Q4) and determining if a case falling into an earlier quartile had an impact on margin status relative to the most recent quartile (Q4). Results: The Q1 cases had an odds ratio for margin positivity of 1.74 compared to Q4 (p=0.1). Multivariate logistic regression did not demonstrate case number to be a significant predictor of PSM. The mean Q1 operative time was 207.4 minutes, decreasing to 179.2 by Q4 (p<0.0001). The mean Q1 estimated blood loss was 255.1 ml, decreasing to 213.6 by Q4 (p=0.0064). There was no change in length of hospitalization within the study period. Conclusions: Even when controlling for copredictors, a statistically significant learning curve for PSM rate of a surgeon with significant previous LRP experience was not detected during the first 400 RARP cases. We hypothesize that previous LRP experience may reduce the RARP PSM learning curve.

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Section: Discussionmentioning

confidence: 99%

Positive surgical margin rates during the robot-assisted laparoscopic radical prostatectomy learning curve of an experienced laparoscopic surgeon

Adili

Giovanni

Kolesar

et al. 2017

CUAJ

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“…1). 3,4 This has previously been validated for use by expert urology surgeons and fellows. Fellows' technical proficiency was scored by their mentor each time they performed a step of RARP in the operating room.…”

Section: Processmentioning

confidence: 99%

“…1). 4 Observation was made of the chronological order of steps of RARP, their difficulty (as designated in the literature), and the order in which the study population undertook them.…”

Section: Identification Of Procedural Steps In a Chronological Mannermentioning

confidence: 99%

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Modular Training for Robot-Assisted Radical Prostatectomy: Where to Begin?

Lovegrove

Ahmed

Novara

et al. 2017

Journal of Surgical Education

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OBJECTIVE: Effective training is paramount for patient safety. Modular training entails advancing through surgical steps of increasing difficulty. This study aimed to construct a modular training pathway for use in robot-assisted radical prostatectomy (RARP). It aims to identify the sequence of procedural steps that are learnt before surgeons are able to perform a full procedure without an intervention from mentor.DESIGN: This is a multi-institutional, prospective, observational, longitudinal study. We used a validated training tool (RARP Score). Data regarding surgeons' stage of training and progress were collected for analysis. A modular training pathway was constructed with consensus on the level of difficulty and evaluation of individual steps. We identified and recorded the sequence of steps performed by fellows during their learning curves. SETTING AND PARTICIPANTS:We included 15 urology fellows from UK, Europe, and Australia.RESULTS: A total of 15 surgeons were assessed by mentors in 425 RARP cases over 8 months (range: 7-79) across 15 international centers. There were substantial differences in the sequence of RARP steps according to the chronology of the procedure, difficulty level, and the order in which surgeons actually learned steps.Steps were not attempted in chronological order. The greater the difficulty, the later the cohort first undertook the step (p ¼ 0.021). The cohort undertook steps of difficulty level I at median case number 1. Steps of difficulty levels II, III, and IV showed more variation in median case number of the first attempt.We recommend that, in the operating theater, steps be learned in order of increasing difficulty. A new modular training route has been designed. This incorporates the steps of RARP with the following order of priority: difficulty level 4 median case number of first attempt 4 most frequently undertaken in surgical training.

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“…A multitude of training programs exists in robotic surgery. Recently, some structured modular training programs were developed with the aim to simplify the learning curve in robotic surgery (13,14): these trainings allowed surgeons with no robotic experience to perform RARP independently, safely, and effectively with subsequent improvement over time but the "advanced" end-points were not evaluable (15). The aim of the present study is to report the early perioperative and functional outcomes after the first 120 cases with a structured intensive modular training program applied to single surgeon with no previous laparoscopic or robotic experience.…”

Section: Introductionmentioning

confidence: 99%

The impact of a structured intensive modular training in the learning curve of robot assisted radical prostatectomy

Schiavina

Borghesi

Dababneh

et al. 2018

Arch Ital Urol Androl

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Aim: The success of Robot Assisted Laparoscopic Prostatectomy (RALP) is mainly due to his relatively short learning curve. Twenty cases are needed to reach a "4 hours-proficiency". However, to achieve optimal functional outcomes such as urinary continence and potency recovery may require more experience. We aim to report the perioperative and early functional outcomes of patients undergoing RALP, after a structured modular training program. Methods: A surgeon with no previous laparoscopic or robotic experience attained a 3 month modular training including: a) e-learning; b) assistance and training to the operating table; c) dry console training; d) step by step in vivo modular training performing 40 surgical steps in increasing difficulty, under the supervision of an experienced mentor. Demographics, intraoperative and postoperative functional outcomes were recorded after his first 120 procedures, considering four groups of 30 cases. Results: All procedures were completed successfully without conversion to open approach. Overall 19 (15%) post operative complications were observed and 84% were graded as minor (Clavien I-II). Overall operative time and console time gradually decreased during the learning curve, with statistical significance in favour of Group 4. The overall continence rate at 1 and 3 months was 74% and 87% respectively with a significant improvement in continence rate throughout the four groups (p = 0.04). Considering those patients submitted to nerve-sparing procedure we found a significant increase in potency recovery over the four groups (p = 0.04) with the higher potency recovery rate up to 80% in the last 30 cases. Conclusions: Optimal perioperative and functional outcomes have been attained since early phase of the learning curve after an intensive structured modular training and less than 100 consecutive procedures seem needed in order to achieve optimal urinary continence and erectile function recovery.KEY WORDS: Training; Robot assisted radical prostatectomy. death in men worldwide (1). Radical prostatectomy (RP) represents the standard surgical treatment for clinically localized prostate cancer (2). Traditionally this procedure was performed with a retropubic open approach retropubic radical prostatectomy (RRP) (3), with the cost of long hospitalization, the need of additional pain medication and significant blood loss. With the aim to reduce morbidity, hospitalization and to improve functional outcomes, minimally invasive approaches including laparoscopic radical prostatectomy (LRP) and robot assisted laparoscopic prostatectomy (RALP) have been increasingly adopted as alternative to open surgery. In the last two decades RALP has gained more popularity and now is a mainstay of treatment for prostate cancer, with functional and oncological outcomes comparable or even better than RRP and LRP (4-6). One of the main reason for the great diffusion of RALP is the short learning curve: contrarily to LRP, where the learning curve is very steep, those surgeons approaching to RALP were able to per...

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Structured and Modular Training Pathway for Robot-assisted Radical Prostatectomy (RARP): Validation of the RARP Assessment Score and Learning Curve Assessment

Cited by 91 publications

References 12 publications

Positive surgical margin rates during the robot-assisted laparoscopic radical prostatectomy learning curve of an experienced laparoscopic surgeon

Positive surgical margin rates during the robot-assisted laparoscopic radical prostatectomy learning curve of an experienced laparoscopic surgeon

Modular Training for Robot-Assisted Radical Prostatectomy: Where to Begin?

The impact of a structured intensive modular training in the learning curve of robot assisted radical prostatectomy

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