Does initial learning curve compromise outcomes for robot-assisted radical cystectomy? A critical evaluation of the first 60 cases while establishing a robotics program.

BACKGROUND AND
PURPOSE: Robot-assisted laparoscopic radical cystectomy (RARC) with pelvic lymph node dissection (PLND) has gained popularity as a minimally invasive alternative to open radical cystectomy (ORC) for the treatment of patients with bladder cancer. The learning curve (LC) for laparoscopic and robotic surgery can be steep. We aim to evaluate the effect of the initial LC on operative, postoperative, and pathologic outcomes of the first 60 RARC performed at our newly established robotics program. PATIENTS AND METHODS: After obtaining Institutional Review Board approval, we reviewed the clinical and pathologic data from 60 consecutive patients with clinically localized bladder cancer who underwent RARC with PLND from January 2008 to March 2010. The patients were grouped into tertiles and assessed for effect of LC using analysis of variance.
RESULTS: Patient demographics and clinical characteristics were similar across tertiles. The mean total operative time trended down from the 1st to 3rd tertile from 525 minutes to 449 minutes, respectively (P=0.059). Mean estimated blood loss was unchanged across tertiles. Complications decreased as the LC progressed from 14 (70%) in the 1st tertile to 6 (30%) in each of the 2nd and 3rd tertiles (P<0.013). The mean total lymph node yield and number of positive margins were unchanged across tertiles.
CONCLUSIONS: RARC with PLND can be performed safely at a high-volume newly established robotic surgery program with an experienced team without compromising operative, postoperative, and short-term pathologic outcomes during the LC for surgeons who are experienced in ORC.