Surgeons slow to learn keyhole surgery for prostate cancer

2 Apr 2009

New research published in the May edition of The Lancet Oncology shows that surgeons who operate on patients with prostate cancer find it harder to learn the skills needed to do the surgery with a laparoscope compared with traditional techniques. The result is that patients are at increased risk of cancer recurrence if they are treated by surgeons who have anything less than the very highest levels of experience.

The findings suggest that as inexperienced surgeons have lower rates of cancer cure, patients should be advised to seek care from specialist cancer centres, where the surgeons specialise in the treatment of just one or two cancers.

The study also showed that the skills needed for laparoscopy (also known as keyhole or minimally invasive surgery) were even harder to pick up for surgeons who already had previous experience of traditional prostate surgery; prompting the authors to comment that, if the results were replicated, “surgeons should not switch between open [traditional] and laparoscopic procedures without a compelling reason.”

Surgery using a laparoscope is done through a much smaller surgical incision than traditional surgery, and compared with traditional surgery it has been shown to reduce recovery time, hospital stay, infection rates, and postoperative pain.

Dr Andrew Vickers (Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, NY, USA) and colleagues previously calculated the learning curve for surgeons doing traditional prostate surgery, and found that the probability that a patient would have a recurrence of prostate cancer after surgery dropped quickly as the surgeons gained experience, levelling off after around 250 surgeries.

In the present study, Vickers and his team calculated the learning curve for surgeons who did prostate surgery using a laparoscope, and found that these surgeons had to do around 750 operations with a laparoscope before they achieved the same low level of disease recurrence as other surgeons achieved after 250 traditional operations.

The researchers also found that surgeons who already had experience of traditional prostate surgery had substantially worse results in terms of cancer recurrence when they first switched to doing surgery using a laparoscope than surgeons whose first experience of prostate surgery was using a laparoscope.

“Improvements in outcome [after surgery for prostate cancer using a laparoscope] seem to accrue more slowly in comparison with open [traditional] surgery,” the authors write, adding that “laparoscopic radical prostatectomy appears to involve skills that do not translate well from open experience.”

The researchers conclude: “Clinical, educational and research initiatives are required in order to moderate the negative effects of the learning curve on clinical care.”