Surgical learning curve for robotic surgery

We on this forum have always cautioned new patients to find the best most experienced high volume surgeon. The following study indicates significant decrease in positive margins and side effects associated with surgery after a learning curve of about 600 to 700 procedures; patients should be very cautious in using surgeons with less than 700 robotic procedures.
The full article is available on The New Prostate Cancer Info link.

The basic results of this study are as follows:
Data from 1,511 patients were included in the positive surgical margin (PSM) analysis.
Data from 609 patients were included in the quality of life (QoL) analysis.
Post-RALP sexual function scores
Surpassed post-ORP sexual function scores after just 99 RALPs
Increased to a mean difference of 11.0 points with the 861st patient
Plateaued at between 600 and 700 RALPs.
Post-RALP early urinary incontinence scores
Surpassed post-ORP early urinary incontinence scores after 182 RALPs
Increased to a mean difference of 8.4 points
Plateaued at between 700 and 800 RALPs.
With respect to risk for PSMs
The risk for a pT2 PSM was initially higher after a RALP than after an ORP.
The risk for a pT2 PSM was lower after a RALP than after an ORP after 108 RALPs.
The risk for a pT2 PSM was 55 percent lower after a RALP than after an ORP after 866 RALPs (odds ratio [OR] = 0.45).
The risk for a pT3/4 PSM was also initially higher after a RALP than after an ORP.
The risk for a pT3/4 PSM after a RALP decreased over time, plateauing at around 200 to 300 RALPs
The risk for a pT3/4 PSM was still 15 percent higher after a RALP than after an ORP after 866 RALPs (OR = 1.15).
Thompson et al. draw a series of significant conclusions from these data:
There is a long learning curve associated with the use of robot-assisted technology in the conduct of RALPs (just as there is for every other type of complex surgery)
Even experienced surgeons should expect to have inferior outcomes initially.
Over time, experience should be associated with progressively superior sexual, early urinary, and pT2 PSM outcomes and similar pT3 PSM and late urinary outcomes.
Learning do do RALPs well over time was worthwhile for this high-volume surgeon, but …
This learning curve may not be justifiable for late-career/low-volume surgeons.

I think nj posted another study showing it was over 1000.

I'm sure there are plenty of surgeons who have performed under 700 surgeries who are very good, btw. I suspect not having long intervals is also critical.

These surgeons work with large teams. It's critical that these teams are fine tuned and "on a roll" when your number is up.

John, this is very interesting and should be quite helpful to folks considering surgery. I recall that in 2008 I posted a study from Johns Hopkins that showed 250 surgeries as the needed number for excellence in open surgery. It would seem that it takes considerably more to master the robot...

Jim

Then there's the usual argument that even the best surgeons can have a bad day.......

And it doesn't mean that patients 1-699 didn't have good surgery and results. I see skill and the number as being very important, but not sure it can be quantified that easy by sheer number. I have heard about some bad things at large facilities that are basically surgery assembly lines.

Still good information.

David

Incho,
I have read a couple of times that at least 250 procedures are necessary for a brachytherapist or radiologist to get good results for prostate cancer.

My sister is a physician and asked around for information from her colleagues on who my husband should use for surgery when he was diagnosed. She was told what John's study shows - that the learning curve is steep for robotic surgery and that a surgeon should have a minimum of 600 surgeries under his belt.

My husband interviewed 2 excellent surgeons. One had done 1000 surgeries and the other had done 3500. I wanted my husband to use the more experienced surgeon (and he did) because I figured that he would be familiar with anything that might come up during surgery. It wasn't the only reason why we chose him, but it was a major factor.

if everyone used a surgeon with 599 surgeries under his belt there would be no surgeons.

ed

David.8,
When my wife asked my uro who would he use if he had PCa, he smiled and didn't hesitate to say Dr. Patel. He was 3 hours away from us here in So. Florida.

Ever wonder who were the poor suckers that had their surgeries performed my surgeons learning how to use the Da Vinci?

I do!

Bill from Florida

clocknut said...
This topic surfaces every once in a while, and every time it bubbles to the top, it causes me to question the wisdom of the entire procedure.

If the study John T quotes is correct about the 600 or 700 surgeries required to achieve proficiency, my "takeaway" is that perhaps the procedure should be outlawed. Why do we sanction a procedure in which each surgeon is treating his or her first several hundred patients with less than optimal likelihood of good results

We wouldn't let a pilot command a commercial airliner until he has demonstrated real proficiency and until he has mastered the required learning curve, but we let a surgeon sit down at the DaVinci console and carve away at men's innards.

I'll admit that I'm being a little facetious. My own surgeon had done only about 50 Da Vinci procedures, though he had decades of experience doing open procedures. And yet, my results have been very good. A good DaVinci surgeon should always be, first and foremost, a good surgeon.

Still, if the learning curve is truly 600 or 700 procedures (or more), the inescapable conclusion is that tens of thousands of men each year are essentially being used as "guinea pigs" for doctors who haven't yet achieved real proficiency in a life-altering procedure. Maybe we should pull the plugs on all those robotic surgical machines until we figure out how to guarantee a higher level of proficiency for everyone being operated on.

I agree that 600 would certainly be more desirable, but many of the reports I've seen suggest that the robotic learning curve is 300-350 surgeries.

Out of respect for John T's study, I would feel better with a surgeon with 600 surgeries and would not accept one with less than 300.

Chuck

Resident of Highland, Indiana just outside of Chicago, IL.
July 2011 local PSA lab reading 6.41 (from 4.1 in 2009). Mayo Clinic PSA Sept. 2011 was 5.7.
Local urologist DRE revealed significant BPH, but no lumps.
PCa Dx Aug. 2011 at age of 61.
Biopsy revealed adenocarcinoma in 3 of 20 cores (one 5%, two 20%). T2C.
Gleason score 3+3=6.
CT of abdomen, bone scan both negative.
DaVinci prostatectomy 11/1/11 at Mayo Clinic (Rochester, MN), nerve sparing, age 62.
My surgeon was Dr. Matthew Tollefson, who I highly recommend.
Final pathology shows tumor confined to prostate.
5 lymph nodes, seminal vesicles, extraprostatic soft tissue all negative.
1.0 x 0.6 x 0.6 cm mass involving right posterior inferior,
right posterior apex & left mid posterior prostate.
Right posterior apex margin involved by tumor over a 0.2 cm length, doctor says this is insignificant.
Pathology showed Gleason 3 + 3, pT2c, N0, MX, R1
adenocarcinoma of the prostate.
Prostate 98.3 grams, tumor 2 grams. Prostate size 5.0 x 4.7 x 4.5 cm.
Abdominal drain removed the morning after surgery.
Catheter out in 7 days. No incontinence, occasional minor dripping.
Post-op exams 2/13/12, 9/10/12, 9/9/13 PSA <0.1. PSA tests now annual.
Firm erections now briefly happening in early mornings, 2 years post-op.

For those that are looking for a surgeon just a few points of advice that worked for me. I learned all these from a great bunch of guys on this site that took the time to answer all my posts, send me info, books, papers e-mails etc. and post their own experience. I just took the top tips I got and put them together below:

1. This is not a race to yank out your organ! Most of us that are here are blessed to have at least a minimum of 3 months if not more to make a wise decision.

2. Please do your homework! Don't just settle for someone who seems confident. Every region if not state has someone that is highly competent and has statistics to back it up.

3. Look for major hospitals that have a Urologic/Oncology department that specializes in PC and Robotic surgery. A 3, 4 or 10 hour drive for that matter is worth every minute!

4. Don't just take your Urologist's or Family Practice doctor's recommendation for a surgeon unless they had the surgery from who they are recommending! Ask for recommendations from experienced patients!

5. If the Doctor or his office can't tell you off the tip of their tongue how many Robotic Surgeries they have done... Move on!

6. Every RALP surgery that is done has an assistant. The assistant is learning. Don't be afraid or timid to confirm with your hand picked, experienced surgeon that he or she is preforming the surgery and the assistant is simply assisting! (I asked mine again right before they put the mask on my face!)

7. If you find the right surgeon and they are not "in network" with your insurance company... fight them on it. It is proven that a successful RALP is highly dependent upon experience. You can fight for coverage based on this point (i.e. The docs that you cover do not have the experience required). Most if not all insurance companies have "bootstrap" insurance partners that they can route your coverage through but they wont give that info up freely.

Why I believe this stuff worked for me?

I took a deep breath and did my own internet research on 5 docs at 4 different hospitals that were recommended to me by patients or friends of mine that have had PC. I called all their offices and made appointments with two of them. At the appointments I asked both of them all the hard questions and I ended up at Mayo Clinic in Rochester, MN with Dr. Matthew Tollefson (He was recommended by someone on this site!). He has done well over 1500 to 2000 now. I couldn't be more pleased with my results! I am 10 weeks out from surgery had great margins on the Path report, I am up to 90% erectile function, fully continent (except with a hard sneeze or cough. :) My wife says welcome to her world!) and my PSA is <0.1

On the flip side I have a new friend I met in the diagnosis period who had his surgery a week before me. He didn't want to drive or fly because he was worried about "missing too much work." He settled on a doc in his hometown that had done "close to" 300 RALP's. My friend is at 11 weeks has no erectile function and is incontinent. It is so disturbing to me that any of us would let someone practice or hone their skills on us. My friend regrets his decision every day. I am hoping and praying he is just on a slower recovery curve.

Clock = you better stated the point I was trying to make. I think by fixating on some number from a study or report, can do a disservice to men seeking a doctor. There are many great surgeons whom due to geographic restrictions, would never reach that many numbers = and it doesn't mean they are not top knotch and great surgeons in their area.

David

doesn't this apply to any surgeon regardless of surgery? I understand some are harder than others, but skill and the ability to master nuances require experience in every single field.

A lot of you were soldiers. Would you rather be in a foxhole with a rookie or a bad*** seasoned vet who has dealt with the situation at hand many times before?

We are dealing with truisms and tautology here.

Results cannot be guaranteed but clearly one increases his chances of success if he chooses and experienced practitioner.