The influence of learning curve of robot‐assisted laparoscopy on oncological outcomes in early‐stage cervical cancer: an observational cohort study

Abstract

Objective To investigate the learning curve of robot-assisted laparoscopy in early-stage cervical cancer and quantify impact on oncological outcomes. Design Observational cohort study. Setting Tertiary referral centre with one surgical team. Population All women with early-stage cervical cancer treated consecutively with robot-assisted laparoscopy between 2007 and 2017. Methods With multivariate risk-adjusted cumulative sum analysis (RA-CUSUM), we assessed the learning curve of robot-assisted laparoscopy of a single surgical team based on cervical cancer recurrence. Subsequently, a survival analysis was conducted comparing oncological outcomes of women treated during different phases of the learning curve. Main outcome measures Surgical proficiency based on recurrence, survival rates in the different learning phases. Results One hundred and sixty-five women with cervical cancer underwent robot-assisted laparoscopy, with a median follow up of 57 months (range 3-132 months). The RA-CUSUM analysis demonstrated two phases of the learning curve: a learning phase of 61 procedures (group 1) and an experienced phase representing the 104 procedures thereafter (group 2). The 5-year disease-free survival was 80.2% in group 1 and 91.1% in group 2 (P = 0.040). Both the 5-year disease-specific survival and overall survival significantly increased after the learning phase. Conclusion The learning phase of robot-assisted laparoscopy in early-stage cervical cancer in this institutional cohort is at least 61 procedures, with higher survival rates in the women treated thereafter. The learning curve of robot-assisted laparoscopy affects oncological outcomes and warrants more attention in the design of future studies.

Increased Institutional Surgical Experience in Robot-Assisted Radical Hysterectomy for Early Stage Cervical Cancer Reduces Recurrence Rate: Results from a Nationwide Study

“…The reduced rate of recurrence and rate of serious postoperative complications, as well as the reduced rate of multiple and intraabdominal recurrences following RRH for early stage cervical cancer with increased surgical experience, must be taken into account when organizing care and counseling the patient prior to surgery. This is supported by a previous Swedish nationwide study as well as two recent publications investigating the influence of learning curve where similar recurrence rates for RRH and ORH were seen at high-volume centers after the implementation period [6,14,15]. When interpreting available studies and performing future studies on RRH for cervical cancer, the negative impact of novel early adopters and low-volume surgeons on the rate of recurrence and postoperative complications must be considered.…”

“…[19,20]. Two recent single-institution studies investigated the impact of learning curve on oncological outcome following RRHs for early stage cervical cancer and found improved survival rates with increased surgical experience, achieving similar levels of adequate experience to our study [14,15]. Neither of the studies discussed or further clarified which elements associated with increased experience would be expected to have a positive effect on recurrence rates.…”

“…Rather than discarding RRHs for early stage cervical cancer, the authors similar to our experience, emphasize the necessity of centralized health care combined with a validated learning curriculum to shorten and make the learning process more effective. In addition, taking into account the institutional oncological outcomes when counseling patients is emphasized [14,15]. The results from these two studies and the present nationwide study might explain the discrepancy in the recurrence rate following RRH and open radical hysterectomy (ORH) in the US register study by Melamed et al and the Swedish study by Alfonzo et al, both national studies including 2461 (978 RRH) and 864 women, respectively [3,6].…”

“…Previous studies have shown a reduction in surgical time, blood loss and the rate of postoperative complications with increased surgical experience after 28-50 surgeries [9][10][11][12][13]. Two recent single institution studies, including 165 and 168 RRH, respectively, demonstrated reduced recurrence rates with increased experience [14,15]. The former used a multivariate risk-adjusted cumulative sum analysis and found a learning phase of 61 RRHs whereas the latter divided their experience based on the year of enrollment, which translated into 77 RRHs [14,15].…”

“…Two recent single institution studies, including 165 and 168 RRH, respectively, demonstrated reduced recurrence rates with increased experience [14,15]. The former used a multivariate risk-adjusted cumulative sum analysis and found a learning phase of 61 RRHs whereas the latter divided their experience based on the year of enrollment, which translated into 77 RRHs [14,15].…”