Learning Curve Analysis for Intracorporeal Robot-assisted Radical Cystectomy: Results from the EAU Robotic Urology Section Scientific Working Group

Carl J Wijburg; Gerjon Hannink; Charlotte T J Michels; Philip C Weijerman; Rami Issa; Andrea Tay; Karel Decaestecker; Peter Wiklund; Abolfazl Hosseini; Ashwin Sridhar; John Kelly; Frederiek d'Hondt; Alexandre Mottrie; Sjoerd Klaver; Sebastian Edeling; Paolo Dell'Oglio; Francesco Montorsi; Maroeska M Rovers; J Alfred Witjes

doi:10.1016/j.euros.2022.03.004

Learning Curve Analysis for Intracorporeal Robot-assisted Radical Cystectomy: Results from the EAU Robotic Urology Section Scientific Working Group

Eur Urol Open Sci. 2022 Apr 2:39:55-61. doi: 10.1016/j.euros.2022.03.004. eCollection 2022 May.

Authors

Carl J Wijburg¹, Gerjon Hannink², Charlotte T J Michels³, Philip C Weijerman¹, Rami Issa⁴, Andrea Tay⁴, Karel Decaestecker⁵, Peter Wiklund⁶, Abolfazl Hosseini⁷, Ashwin Sridhar⁸, John Kelly⁸, Frederiek d'Hondt⁹, Alexandre Mottrie⁹, Sjoerd Klaver¹⁰, Sebastian Edeling¹¹, Paolo Dell'Oglio¹², Francesco Montorsi¹³, Maroeska M Rovers^{2

3}, J Alfred Witjes¹⁴

Affiliations

¹ Department of Urology, Rijnstate Hospital, Arnhem, The Netherlands.
² Department of Operating Rooms, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands.
³ Department for Health Evidence, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands.
⁴ Department of Urology, St. George's University Hospitals, London, UK.
⁵ Department of Urology, University Hospital Gent, Gent, Belgium.
⁶ Department of Urology, Mount Sinai Hospital, New York, NY, USA.
⁷ Department of Urology, Karolinska University Hospital, Stockholm, Sweden.
⁸ Department of Urology, University College London Hospitals, London, UK.
⁹ Department of Urology, Onze Lieve Vrouw Hospital, Aalst, Belgium.
¹⁰ Department of Urology, Maasstad Hospital, Rotterdam, The Netherlands.
¹¹ Department of Urology, Vinzenz Hospital, Hannover, Germany.
¹² Department of Urology, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy.
¹³ Department of Urology, Division of Oncology, Urological Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy.
¹⁴ Department of Urology, Radboud University Medical Center, Nijmegen, The Netherlands.

Abstract

Background: The utilisation of robot-assisted radical cystectomy with intracorporeal reconstruction (iRARC) has increased in recent years. Little is known about the length of the learning curve (LC) for this procedure.

Objective: To study the length of the LC for iRARC in terms of 90-d major complications (MC90; Clavien-Dindo grade ≥3), 90-d overall complications (OC90, Clavien-Dindo grades 1-5), operating time (OT), estimated blood loss (EBL), and length of hospital stay (LOS).

Design setting and participants: This was a retrospective analysis of all consecutive iRARC cases from nine European high-volume hospitals with ≥100 cases. All patients had bladder cancer for which iRARC was performed, with an ileal conduit or neobladder as the urinary diversion.

Outcome measurements and statistical analysis: Outcome parameters used as a proxy for LC length were the number of consecutive cases needed to reach a plateau level in two-piece mixed-effects models for MC90, OC90, OT, EBL, and LOS.

Results and limitations: A total of 2186 patients undergoing iRARC between 2003 and 2018were included. The plateau levels for MC90 and OC90 were reached after 137 cases (95% confidence interval [CI] 80-193) and 97 cases (95% CI 41-154), respectively. The mean MC90 rate at the plateau was 14% (95% CI 7-21%). The plateau level was reached after 75 cases (95% CI 65-86) for OT, 88 cases (95% CI 70-106) for EBL, and 198 cases (95% CI 130-266) for LOS. A major limitation of the study is the difference in the balance of urinary diversion types between centres.

Conclusions: This multicentre retrospective analysis for the iRARC LC among nine European centres showed that 137 consecutive cases were needed to reach a stable MC90 rate.

Patient summary: We carried out a multicentre analysis of the surgical learning curve for robot-assisted removal of the bladder and bladder reconstruction in patients with bladder cancer. We found that 137 consecutive cases were needed to reach a stable rate of serious complications.

Keywords: Bladder cancer; Complications; Intracorporeal; Learning curve; Radical cystectomy; Robot-assisted.