Does RALP learning curve impact on patients’ outcomes?

Sara Melegari1, Mauro Seveso1, Giorgio Bozzini1, Oliviero De Francesco1, Pietro Bono1, Alberto Mandressi1, Gianluigi Taverna1
  • 1 Humanitas Mater Domini (Castellanza)


RALP learning curve is associated with long operating times, inferior operatory and post-operatory outcomes and an increased number of complications.
We report the initial results of 80 RALP procedures performed in our Institute , with the introduction of a new surgeon laparoscopically trained that followed a modular structured program.
The aim of this study is to evaluate if our approach to training would yield a safer outcomes for patients undergoing the procedure during the learning curve.

Materials and Methods

From 06.2015 to 06.2016 a new surgeon began a training program in RALP. He was open and laparoscopically trained . RARP procedure was splitted into steps: opening peritoneum and bladder takedown ( 5 cases) , endopelvic fascia and bladder neck (12 cases), seminal vesicle/vas deferens (15 cases), pedicle/nerve sparing and apex (12 cases), posterior dissection and posterior bladder neck transection ( 15 cases), anastomosis with reconstruction as described by Porpiglia (10 cases), lymphadenectomy ( according to guidelines)( 11 cases) . In all procedure the training surgeon performed a single step of RALP under supervision of an experienced preceptor. Consolle time and perioperative variables were compared to 80 surgeon-only cases.


The median surgical time was not significantly different between the two cohort of patients (160 min vs 150 min; p NS) . The median estimated blood loss was 200 ml. There was no difference in positive margins , length of stay , catheter days , readmission . There were 2 complications Clavien II(anemia that required blood transfusion) and 6 Clavien IIIa (5 drainage for lymphocele and 1 urinary leakage), no conversions nor transfusions. The median hospital stay was 3 days. The median catheterization time was 7 days. The biochemical recurrence-free survival rate (PSA < 0.01 ng/ml) was 94 % over an average follow-up of 6 months. The continence rates were (no pad) 70 % within 3 months and 90 % within 6 months with no difference between the two group.


The introduction of a new surgeon in robotic team and the impact of learning curve on oncological, functional and perioperative outcomes is actually object of debate; as confirmed by the raising of studies focused on modality of teaching RALP.
Like most of studies reported in literature, we splitted RALP in steps but in our clinical practice the training surgeon performed just one step in each procedure, even if he had already completed the learning curve of other steps, with the aim of not impact on surgical time and focus attention in the step in-training.
Similarly to our study, Schommer [1] et al splitted the procedure in steps and they examined perioperative outcomes of resident involvement during various steps of robot-assisted radical prostatectomy (RARP) concluding that supervised resident console involvement did not affect perioperative outcomes, although, it prolongs surgical time, with the bladder takedown step having the most effect.
Wang et al [2] reported that a new surgeon joining a high-volume robotic prostatectomy program with an established robotic team and mentorship can progress through the learning curve without compromising overall outcomes of the practice.
Lovegrove et al [3] developed and validated a modular training and assessment pathway via Healthcare Failure Mode and Effect Analysis (HFMEA) for trainees undertaking RARP and evaluate learning curves for procedural steps. The RARP Assessment Score based on HFMEA methodology identified critical steps for focused RARP training and assessed surgeons. They reported the experience necessary to reach a level of competence in technical skills to protect patients: 16 cases for anterior bladder neck transection , 18 cases for posterior bladder neck transection , 9 cases for posterior dissection , 15 cases for dissection of prostatic pedicle and seminal vesicles and 17 cases for anastomosis .
In our experience the learning curve of the new surgeon was shorter, this may be caused by his previous large experience in open surgery , laparoscopy and table surgeon in about 300 RALP.
This hypothesis may be confirmed by Ku et al [4] ; indeed they reported that previous large-volume experience of laparoscopic radical may shorten the learning curve for RARP in terms of oncological outcome as well as , previous experience with laparoscopy may improve the functional outcomes of RARP.
As far as surgical team experience overall is concerned, an experienced surgical team, in general, and the surgeon assistant in particular are believed to play a critical role in the operation's safety and success; anyway as Abu- Ghanem [5] showed, the assistant's seniority has no influence on perioperative course following RALP. Consequently, given a highly experienced primary surgeon, a less experienced assistant can be safely incorporated into this procedure.
Obviously, whenever disposable, a dual-console system may improve intraoperative and perioperative outcomes , representing a safe and more efficient modality for robotic surgical education as compared to a single-console system , as reported by Morgan et al [6].


The implementation of a training program in which the trained surgeon is involved in at least one portion of RARP allowed us to overcome the initial learning curve with no difference in perioperatory outcomes, oncological and functional results .


1. Schommer E, Tonkovich K, Li 2, Thiel DD. “ Impact of Resident Involvement on Robot-Assisted Radical Prostatectomy Outcomes”. J Endourol. 2016 Oct;30(10):1126-1131.

2. Wang L, Diaz M, Stricker H, Peabody JO, Menon M, Rogers CG. “Adding a newly trained surgeon into a high-volume robotic prostatectomy group: are outcomes compromised?” J Robot Surg. 2016 Jun 27.

3. Lovegrove C, Novara G, Mottrie A, Guru KA, Brown M, Challacombe B, Popert R, Raza J, Van der Poel H, Peabody J, Dasgupta P, Ahmed K. “Structured and Modular Training Pathway for Robot-assisted Radical Prostatectomy (RARP): Validation of the RARP Assessment Score and Learning Curve Assessment”. Eur Urol. 2016 Mar;69(3):526-35.

4. Ku JY, Ha HK.”Learning curve of robot-assisted laparoscopic radical prostatectomy for a single experienced surgeon: comparison with simultaneous laparoscopic radical prostatectomy”.
World J Mens Health. 2015 Apr;33(1):30-5

5. Abu-Ghanem Y, Erlich T, Ramon J, Dotan Z, Zilberman DE. “Robot assisted laparoscopic radical prostatectomy: assistant's seniority has no influence on perioperative course”. J Robot Surg. 2016 Nov 9.

6. Morgan MS1, Shakir NA, Garcia-Gil M, Ozayar A, Gahan JC, Friedlander JI, Roehrborn CG, Cadeddu JA. “ Single- versus dual-console robot-assisted radical prostatectomy: impact on intraoperative and postoperative outcomes in a teaching institution” . World J Urol. 2015 Jun;33(6):781-6.