To perform a systematic search and review of the available literature on the learning curves (LCs) in laparoscopic and robot-assisted prostate surgery.
Medline was systematically searched from 1946 to January 2021 to detect all studies in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement, reporting on the LC in laparoscopic radical prostatectomy (LRP), laparoscopic simple prostatectomy (LSP), robot-assisted radical prostatectomy (RARP) and robot-assisted simple prostatectomy (RSP).
In total, 47 studies were included for qualitative synthesis evaluating a single technique (LRP, RARP, LSP, RSP; 45 studies) or two techniques (LRP and RARP; 2 studies). All studies evaluated outcomes on real patients. RARP was the most widely investigated technique (30 studies), followed by LRP (17 studies), LSP (1 study), and RSP (1 study). In LRP, the reported LC based on operative time; estimated blood loss; length of hospital stay; positive surgical margin; biochemical recurrence; overall complication rate; and urinary continence rate ranged 40–250, 80–250, 58–200, 50–350, 110–350, 55–250, 70–350 cases, respectively. In RARP, the corresponding ranges were 16–300, 20–300, 25–200, 50–400, 40–100, 20–250, 30–200, while LC for potency rates was 80–90 cases.
The definition of LC for laparoscopic and robot-assisted prostate surgery is not well defined with various metrics used among studies. Nevertheless, LCs appear to be steep and continuous. Implementation of training programs/standardization of the techniques is necessary to improve outcomes.
This is a preview of subscription content, access via your institution.
Buy single article
Instant access to the full article PDF.
Tax calculation will be finalised during checkout.
Availability of data and material
Available in corresponding authors database.
Abboudi H, Khan MS, Guru KA, Froghi S, de Win G, Van Poppel H, Dasgupta P, Ahmed K (2014) Learning curves for urological procedures: a systematic review. BJU Int 114:617–629. https://doi.org/10.1111/bju.12315
Kassite I, Bejan-Angoulvant T, Lardy H, Binet A (2019) A systematic review of the learning curve in robotic surgery: range and heterogeneity. Surg Endosc 33:353–365. https://doi.org/10.1007/s00464-018-6473-9
Kaul S, Shah NL, Menon M (2006) Learning curve using robotic surgery. Curr Urol Rep 7:125–129. https://doi.org/10.1007/s11934-006-0071-4
Bach PB, Cramer LD, Schrag D, Downey RJ, Gelfand SE, Begg CB (2001) The influence of hospital volume on survival after resection for lung cancer. N Engl J Med 345:181–188. https://doi.org/10.1056/NEJM200107193450306
Schrag D, Panageas KS, Riedel E, Cramer LD, Guillem JG, Bach PB, Begg CB (2002) Hospital and surgeon procedure volume as predictors of outcome following rectal cancer resection. Ann Surg 236:583–592. https://doi.org/10.1097/00000658-200211000-00008
Artibani W, Novara G (2008) Cancer-related outcome and learning curve in retropubic radical prostatectomy: “if you need an operation, the most important step is to choose the right surgeon.” Eur Urol 53:874–876. https://doi.org/10.1016/j.eururo.2008.01.087
Rassweiler MC, Mamoulakis C, Kenngott HG, Rassweiler J, de la Rosette J, Laguna MP (2011) Classification and detection of errors in minimally invasive surgery. J Endourol 25:1713–1721. https://doi.org/10.1089/end.2011.0068
Soomro NA, Hashimoto DA, Porteous AJ, Ridley CJA, Marsh WJ, Ditto R, Roy S (2020) Systematic review of learning curves in robot-assisted surgery. BJS Open 4:27–44. https://doi.org/10.1002/bjs5.50235
Moher D, Liberati A, Tetzlaff J, Altman DG, Group P (2009) Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med 6:e1000097. https://doi.org/10.1371/journal.pmed.1000097
Baumert H, Fromont G, Adorno Rosa J, Cahill D, Cathelineau X, Vallancien G (2004) Impact of learning curve in laparoscopic radical prostatectomy on margin status: prospective study of first 100 procedures performed by one surgeon. J Endourol 18:173–176. https://doi.org/10.1089/089277904322959824
Eden CG, Neill MG, Louie-Johnsun MW (2009) The first 1000 cases of laparoscopic radical prostatectomy in the UK: evidence of multiple “learning curves.” BJU Int 103:1224–1230. https://doi.org/10.1111/j.1464-410X.2008.08169.x
Vickers AJ, Savage CJ, Hruza M, Tuerk I, Koenig P, Martínez-Piñeiro L, Janetschek G, Guillonneau B (2009) The surgical learning curve for laparoscopic radical prostatectomy: a retrospective cohort study. Lancet Oncol 10:475–480. https://doi.org/10.1016/s1470-2045(09)70079-8
Secin FP, Savage C, Abbou C, de La Taille A, Salomon L, Rassweiler J, Hruza M, Rozet F, Cathelineau X, Janetschek G, Nassar F, Turk I, Vanni AJ, Gill IS, Koenig P, Kaouk JH, Martinez Pineiro L, Pansadoro V, Emiliozzi P, Bjartell A, Jiborn T, Eden C, Richards AJ, Van Velthoven R, Stolzenburg JU, Rabenalt R, Su LM, Pavlovich CP, Levinson AW, Touijer KA, Vickers A, Guillonneau B (2010) The learning curve for laparoscopic radical prostatectomy: an international multicenter study. J Urol 184:2291–2296. https://doi.org/10.1016/j.juro.2010.08.003
Hruza M, Weiss HO, Pini G, Goezen AS, Schulze M, Teber D, Rassweiler JJ (2010) Complications in 2200 consecutive laparoscopic radical prostatectomies: standardised evaluation and analysis of learning curves. Eur Urol 58:733–741. https://doi.org/10.1016/j.eururo.2010.08.024
Rodriguez AR, Rachna K, Pow-Sang JM (2010) Laparoscopic extraperitoneal radical prostatectomy: impact of the learning curve on perioperative outcomes and margin status. Jsls 14:6–13. https://doi.org/10.4293/108680809x12589998404209
So BK, Choi JD, Lee SY, Kim HS, Park SY, Seo SI (2011) Experience of 100 laparoscopic radical prostatectomies performed by a single surgeon: an analysis of surgical and functional outcomes. Korean J Urol 52:517–523. https://doi.org/10.4111/kju.2011.52.8.517
Vasdev N, Kass-Iliyya A, Patel A, Bedford G, O’Riordon A, Johnson MI, Durkan GC, Soomro NA (2012) Developing a laparoscopic radical prostatectomy service: defining the learning curve. J Endourol 26:903–910. https://doi.org/10.1089/end.2011.0635
Di Gioia RF, Rubinstein M, Velasque L, Rubinstein I (2013) Impact of a low-volume laparoscopic radical prostatectomy learning curve on perioperative outcomes: is it acceptable? J Laparoendosc Adv Surg Tech A 23:841–848. https://doi.org/10.1089/lap.2013.0160
Mitre AI, Chammas MF Jr, Rocha JE Jr, Duarte RJ, Ebaid GX, Rocha FT (2013) Laparoscopic radical prostatectomy: the learning curve of a low volume surgeon. ScientificWorldJournal 2013:974276. https://doi.org/10.1155/2013/974276
Good DW, Stewart GD, Stolzenburg JU, McNeill SA (2014) Analysis of the pentafecta learning curve for laparoscopic radical prostatectomy. World J Urol 32:1225–1233. https://doi.org/10.1007/s00345-013-1198-9
Mason S, Van Hemelrijck M, Chandra A, Brown C, Cahill D (2016) Laparoscopic radical prostatectomy outcome data: how should surgeon’s performance be reported? A retrospective learning curve analysis of two surgeons. Ecancermedicalscience 10:651. https://doi.org/10.3332/ecancer.2016.651
Barbosa HN Jr, Siqueira TM Jr, Barreto F, Menezes LG, Luna MJ, Calado AA (2016) 4-Ports endoscopic extraperitoneal radical prostatectomy: preliminary and learning curve results. Int Braz J Urol 42:438–448. https://doi.org/10.1590/s1677-5538.ibju.2015.0323
Sivaraman A, Sanchez-Salas R, Prapotnich D, Yu K, Olivier F, Secin FP, Barret E, Galiano M, Rozet F, Cathelineau X (2017) Learning curve of minimally invasive radical prostatectomy: comprehensive evaluation and cumulative summation analysis of oncological outcomes. Urol Oncol 35:149.e141-149.e146. https://doi.org/10.1016/j.urolonc.2016.10.015
Handmer M, Chabert C, Cohen R, Gianduzzo T, Kearns P, Moon D, Ooi J, Shannon T, Sofield D, Tan A, Louie-Johnsun M (2018) The Australian laparoscopic radical prostatectomy learning curve. ANZ J Surg 88:100–103. https://doi.org/10.1111/ans.14025
Good DW, Stewart GD, Laird A, Stolzenburg JU, Cahill D, McNeill SA (2015) A critical analysis of the learning curve and postlearning curve outcomes of two experience- and volume-matched surgeons for laparoscopic and robot-assisted radical prostatectomy. J Endourol 29:939–947. https://doi.org/10.1089/end.2014.0810
Dias JAN, Dall’oglio MF, Colombo JR Jr, Coelho RF, Nahas WC (2017) The influence of previous robotic experience in the initial learning curve of laparoscopic radical prostatectomy. Int Braz J Urol 43:871–879. https://doi.org/10.1590/s1677-5538.ibju.2016.0526
Atug F, Castle EP, Srivastav SK, Burgess SV, Thomas R, Davis R (2006) Positive surgical margins in robotic-assisted radical prostatectomy: impact of learning curve on oncologic outcomes. Eur Urol 49:866–871. https://doi.org/10.1016/j.eururo.2006.02.054 ((discussion 871–862))
Artibani W, Fracalanza S, Cavalleri S, Iafrate M, Aragona M, Novara G, Gardiman M, Ficarra V (2008) Learning curve and preliminary experience with da Vinci-assisted laparoscopic radical prostatectomy. Urol Int 80:237–244. https://doi.org/10.1159/000127333
Doumerc N, Yuen C, Savdie R, Rahman MB, Pe Benito R, Stricker P (2010) Robot-assisted laparoscopic prostatectomy: analysis of an experienced open surgeon’s learning curve after 300 procedures. J Robot Surg 3:229–234. https://doi.org/10.1007/s11701-010-0171-5
Sharma NL, Papadopoulos A, Lee D, McLoughlin J, Vowler SL, Baumert H, Warren AY, Patil V, Shah N, Neal DE (2011) First 500 cases of robotic-assisted laparoscopic radical prostatectomy from a single UK centre: learning curves of two surgeons. BJU Int 108:739–747. https://doi.org/10.1111/j.1464-410X.2010.09941.x
Sammon J, Perry A, Beaule L, Kinkead T, Clark D, Hansen M (2010) Robot-assisted radical prostatectomy: learning rate analysis as an objective measure of the acquisition of surgical skill. BJU Int 106:855–860. https://doi.org/10.1111/j.1464-410X.2009.09187.x
Ou YC, Yang CR, Wang J, Cheng CL, Patel VR (2010) Robotic-assisted laparoscopic radical prostatectomy: learning curve of first 100 cases. Int J Urol 17:635–640. https://doi.org/10.1111/j.1442-2042.2010.02546.x
Ou YC, Yang CR, Wang J, Yang CK, Cheng CL, Patel VR, Tewari AK (2011) The learning curve for reducing complications of robotic-assisted laparoscopic radical prostatectomy by a single surgeon. BJU Int 108:420–425. https://doi.org/10.1111/j.1464-410X.2010.09847.x
Ou YC, Yang CR, Wang J, Cheng CL, Patel VR (2011) Learning curve of robotic-assisted radical prostatectomy with 60 initial cases by a single surgeon. Asian J Surg 34:74–80. https://doi.org/10.1016/s1015-9584(11)60023-7
Gumus E, Boylu U, Turan T, Onol FF (2011) The learning curve of robot-assisted radical prostatectomy. J Endourol 25:1633–1637. https://doi.org/10.1089/end.2011.0071
Dal Moro F, Secco S, Valotto C, Artibani W, Zattoni F (2012) Specific learning curve for port placement and docking of da Vinci(®) Surgical System: one surgeon’s experience in robotic-assisted radical prostatectomy. J Robot Surg 6:323–327. https://doi.org/10.1007/s11701-011-0315-2
Al-Hathal N, El-Hakim A (2013) Perioperative, oncological and functional outcomes of the first robotic prostatectomy program in Quebec: single fellowship-trained surgeon’s experience of 250 cases. Can Urol Assoc J 7:326–332. https://doi.org/10.5489/cuaj.319
Hashimoto T, Yoshioka K, Gondo T, Kamoda N, Satake N, Ozu C, Horiguchi Y, Namiki K, Nakashima J, Tachibana M (2013) Learning curve and perioperative outcomes of robot-assisted radical prostatectomy in 200 initial Japanese cases by a single surgeon. J Endourol 27:1218–1223. https://doi.org/10.1089/end.2013.0235
Seo DY, Cho HJ, Cho JM, Kang JY, Yoo TK (2013) Experience with robot-assisted laparoscopic radical prostatectomy at a secondary training hospital: operation time, treatment outcomes, and complications with the accumulation of experience. Korean J Urol 54:522–526. https://doi.org/10.4111/kju.2013.54.8.522
Vasdev N, Bishop C, Kass-Iliyya A, Hamid S, McNicholas TA, Prasad V, Mohan SG, Lane T, Boustead G, Adshead JM (2013) Developing a robotic prostatectomy service and a robotic fellowship programme—defining the learning curve. Curr Urol 7:136–144. https://doi.org/10.1159/000356266
Di Pierro GB, Wirth JG, Ferrari M, Danuser H, Mattei A (2014) Impact of a single-surgeon learning curve on complications, positioning injuries, and renal function in patients undergoing robot-assisted radical prostatectomy and extended pelvic lymph node dissection. Urology 84:1106–1111. https://doi.org/10.1016/j.urology.2014.06.047
Thompson JE, Egger S, Böhm M, Haynes AM, Matthews J, Rasiah K, Stricker PD (2014) Superior quality of life and improved surgical margins are achievable with robotic radical prostatectomy after a long learning curve: a prospective single-surgeon study of 1552 consecutive cases. Eur Urol 65:521–531. https://doi.org/10.1016/j.eururo.2013.10.030
Ou YC, Yang CK, Chang KS, Wang J, Hung SW, Tung MC, Tewari AK, Patel VR (2014) The surgical learning curve for robotic-assisted laparoscopic radical prostatectomy: experience of a single surgeon with 500 cases in Taiwan, China. Asian J Androl 16:728–734. https://doi.org/10.4103/1008-682x.128515
Chang Y, Qu M, Wang L, Yang B, Chen R, Zhu F, Wang H, Wang Y, Lu X, Ma C, Shi Z, Dong Z, Chen H, Xu C, Sun Y, Gao X (2016) Robotic-assisted laparoscopic radical prostatectomy from a single Chinese center: a learning curve analysis. Urology 93:104–111. https://doi.org/10.1016/j.urology.2016.03.036
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 (2016) Structured and modular training pathway for robot-assisted radical prostatectomy (RARP): validation of the RARP assessment score and learning curve assessment. Eur Urol 69:526–535. https://doi.org/10.1016/j.eururo.2015.10.048
Adili AF, Di Giovanni J, Kolesar E, Wong NC, Hoogenes J, Dason S, Shayegan B (2017) Positive surgical margin rates during the robot-assisted laparoscopic radical prostatectomy learning curve of an experienced laparoscopic surgeon. Can Urol Assoc J 11:E409-e413. https://doi.org/10.5489/cuaj.4588
Jaulim A, Srinivasan A, Hori S, Kumar N, Warren AY, Shah NC, Gnanapragasam VJ (2018) A comparison of operative and margin outcomes from surgeon learning curves in robot assisted radical prostatectomy in a changing referral practice. Ann R Coll Surg Engl 100:226–229. https://doi.org/10.1308/rcsann.2018.0001
Ucar M, Varol AT, Gülkesen KH, Caylan AE, Kutlu Ö, Güntekin E (2019) Does the learning curve affect the surgical, functional, and oncologic outcomes in bilateral nerve-sparing robot assisted laparoscopic prostatectomy? Cureus 11:e5274. https://doi.org/10.7759/cureus.5274
Slusarenco RI, Mikheev KV, Prostomolotov AO, Sukhanov RB, Bezrukov EA (2020) Analysis of learning curve in robot-assisted radical prostatectomy performed by a surgeon. Adv Urol 2020:9191830. https://doi.org/10.1155/2020/9191830
Song W, Lee SW, Chung JH, Kang M, Sung HH, Jeon HG, Jeong BC, Seo SI, Lee HM, Jeon SS (2020) Relationship between robotic-assisted radical prostatectomy and retropubic radical prostatectomy in the learning curve of a single surgeon as a novice in radical prostatectomy: a retrospective cohort study. Int J Surg 81:74–79. https://doi.org/10.1016/j.ijsu.2020.07.006
Tamhankar A, Spencer N, Hampson A, Noel J, El-Taji O, Arianayagam R, McNicholas T, Boustead G, Lane T, Adshead J, Vasdev N (2020) Real-time assessment of learning curve for robot-assisted laparoscopic prostatectomy. Ann R Coll Surg Engl 102:717–725. https://doi.org/10.1308/rcsann.2020.0139
Bonet X, Moschovas MC, Onol FF, Bhat KR, Rogers T, Ogaya-Pinies G, Rocco B, Sighinolfi MC, Woodlief T, Vigués F, Patel V (2020) The surgical learning curve for salvage robot-assisted radical prostatectomy: a prospective single-surgeon study. Minerva Urol Nefrol. https://doi.org/10.23736/s0393-2249.20.04077-1
Davis JW, Kreaden US, Gabbert J, Thomas R (2014) Learning curve assessment of robot-assisted radical prostatectomy compared with open-surgery controls from the premier perspective database. J Endourol 28:560–566. https://doi.org/10.1089/end.2013.0534
Fossati N, Di Trapani E, Gandaglia G, Dell’Oglio P, Umari P, Buffi NM, Guazzoni G, Mottrie A, Gaboardi F, Montorsi F, Briganti A, Suardi N (2017) Assessing s. J Endourol 31:872–877. https://doi.org/10.1089/end.2017.0085
Yun HK, Kwon JB, Cho SR, Kim JS (2010) Early experience with laparoscopic retropubic simple prostatectomy in patients with voluminous benign prostatic hyperplasia (BPH). Korean J Urol 51:323–329. https://doi.org/10.4111/kju.2010.51.5.323
Johnson B, Sorokin I, Singla N, Roehrborn C, Gahan JC (2018) Determining the learning curve for robot-assisted simple prostatectomy in surgeons familiar with robotic surgery. J Endourol 32:865–870. https://doi.org/10.1089/end.2018.0377
Patel VR, Sivaraman A, Coelho RF, Chauhan S, Palmer KJ, Orvieto MA, Camacho I, Coughlin G, Rocco B (2011) Pentafecta: a new concept for reporting outcomes of robot-assisted laparoscopic radical prostatectomy. Eur Urol 59:702–707. https://doi.org/10.1016/j.eururo.2011.01.032
Good D, Stewart G, Stolzenburg J, McNeill S (2014) A literature-based analysis of the learning curves of laparoscopic radical prostatectomy. EMJ Urol 1:90–96.
Yao A, Iwamoto H, Masago T, Morizane S, Honda M, Sejima T, Takenaka A (2015) Anatomical dimensions using preoperative magnetic resonance imaging: impact on the learning curve of robot-assisted laparoscopic prostatectomy. Int J Urol 22:74–79. https://doi.org/10.1111/iju.12602
Garbens A, Lay AH, Steinberg RL, Gahan JC (2020) Experienced bedside-assistants improve operative outcomes for surgeons early in their learning curve for robot assisted laparoscopic radical prostatectomy. J Robot Surg. https://doi.org/10.1007/s11701-020-01146-8
Abdel Raheem A, Song HJ, Chang KD, Choi YD, Rha KH (2017) Robotic nurse duties in the urology operative room: 11 years of experience. Asian J Urol 4:116–123. https://doi.org/10.1016/j.ajur.2016.09.012
Gregorio SA, Rivas JG, Molina SS, Gomez AT, Ledo JC, Sebastian JD, Barthel JJ (2014) Laparoscopic radical prostatectomy training for residents: Hospital Universitario La Paz model. Cent Eur J Urol 67:247–252. https://doi.org/10.5173/ceju.2014.03.art7
Cimen HI, Atik YT, Altinova S, Adsan O, Balbay MD (2019) Does the experience of the bedside assistant effect the results of robotic surgeons in the learning curve of robot assisted radical prostatectomy? Int Braz J Urol 45:54–60. https://doi.org/10.1590/s1677-5538.ibju.2018.0184
Chen A, Ghodoussipour S, Titus MB, Nguyen JH, Chen J, Ma R, Hung AJ (2020) Comparison of clinical outcomes and automated performance metrics in robot-assisted radical prostatectomy with and without trainee involvement. World J Urol 38:1615–1621. https://doi.org/10.1007/s00345-019-03010-3
Almarzouq A, Hu J, Noureldin YA, Yin A, Anidjar M, Bladou F, Tanguay S, Kassouf W, Aprikian AG, Andonian S (2020) Are basic robotic surgical skills transferable from the simulator to the operating room? A randomized, prospective, educational study. Can Urol Assoc J 14:416–422. https://doi.org/10.5489/cuaj.6460
Chandak P, Byrne N, Lynch H, Allen C, Rottenberg G, Chandra A, Raison N, Ahmed H, Kasivisvanathan V, Elhage O, Dasgupta P (2018) Three-dimensional printing in robot-assisted radical prostatectomy—an Idea, Development, Exploration, Assessment, Long-term follow-up (IDEAL) Phase 2a study. BJU Int 122:360–361. https://doi.org/10.1111/bju.14189
Lovegrove CE, Elhage O, Khan MS, Novara G, Mottrie A, Dasgupta P, Ahmed K (2017) Training modalities in robot-assisted urologic surgery: a systematic review. Eur Urol Focus 3:102–116. https://doi.org/10.1016/j.euf.2016.01.006
Chen J, Cheng N, Cacciamani G, Oh P, Lin-Brande M, Remulla D, Gill IS, Hung AJ (2019) Objective assessment of robotic surgical technical skill: a systematic review. J Urol 201:461–469. https://doi.org/10.1016/j.juro.2018.06.078
Vickers A, Bianco F, Cronin A, Eastham J, Klein E, Kattan M, Scardino P (2010) The learning curve for surgical margins after open radical prostatectomy: implications for margin status as an oncological end point. J Urol 183:1360–1365. https://doi.org/10.1016/j.juro.2009.12.015
Conflict of interest
The authors declare that they have no conflict of interest.
Research involving human participants and/or animal
This research is a review paper and does not involve research on humans or animals.
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
About this article
Cite this article
Grivas, N., Zachos, I., Georgiadis, G. et al. Learning curves in laparoscopic and robot-assisted prostate surgery: a systematic search and review. World J Urol (2021). https://doi.org/10.1007/s00345-021-03815-1
- Learning curve
- Robotic surgical procedures
- Systematic review