Should experienced open prostatic surgeons convert to robotic surgery? The real learning curve for one surgeon over 3 years.

OBJECTIVE: To critically analyse the learning curve for one experienced open surgeon converting to robotic surgery for radical prostatectomy (RP). PATIENTS AND METHODS: From February 2006 to December 2008, 502 patients had retropubic RP (RRP) while concurrently 212 had robot-assisted laparoscopic RP (RALP) by one urologist. We prospectively compared the baseline patient and tumour characteristics, variables during and after RP, histopathological features and early urinary functional outcomes in the two groups. RESULTS: The patients in both groups were similar in age, preoperative prostate-specific antigen level, and prostatic volume. However, there were more high-stage (T2b and T3, P = 0.02) and -grade (Gleason 9, P = 0.01) tumours in the RRP group. The mean (range) operative duration was 147 (75-330) min for RRP and 192 (119-525) min for RALP (P < 0.001); 110 cases were required to achieve '3-h proficiency'. Major complication rates were 1.8% and 0.8% for RALP and RRP, respectively. The overall positive surgical margin (PSM) rate was 21.2% in the RALP and 16.7% in the RRP group (P = 0.18). PSM rates for pT2 were comparable (11.6% vs 10.1%, P = 0.74). pT3 PSM rates were higher for RALP than RRP (40.5% vs 28.8%, P = 0.004). The learning curve started to plateau in the overall PSM rate after 150 cases. For the pT2 and pT3 PSM rates, the learning curve tended to flatten after 140 and 170 cases, respectively. The early continence rates were comparable (P = 0.07) but showed a statistically significant improvement after 200 cases. CONCLUSIONS: Our analysis of the learning curve has shown that certain components of the curve for an experienced open surgeon transferring skills to the robotic platform take different times. We suggest that patient selection is guided by these milestones, to maximize oncological outcomes.

Prognostic significance of Gleason pattern in patients with Gleason score 7 prostate carcinoma.

BACKGROUND: In the current study, the authors sought to further stratify the prognosis of patients with Gleason score (GS) 7 prostate carcinoma. They assessed the influence on outcome of a predominant poorly differentiated Gleason pattern (primary Gleason pattern [GP] 4) and/or a coincident small focus of poorly differentiated tumor of higher grade (tertiary GP 5). METHODS: The authors studied 412 patients (mean postoperative follow-up, 33 months) with GS 7 tumors treated with radical prostatectomy at a single Australian campus between November 1989 and December 2002. The chi-square test, Kaplan-Meier method, and Cox proportional hazards analyses were used to evaluate the correlation between primary GP 4 and tertiary GP 5 with the occurrence of adverse pathologic features and disease recurrence. RESULTS: In this cohort, 307 patients (75%) had primary GP 3 tumors, 105 (25%) had primary GP 4 tumors, and 17 (2.3%) had a tertiary element of high-grade tumor (GP 5). Patients with primary GP 4 tumors displayed higher rates of seminal vesicle involvement and extraprostatic extension and, along with patients with tertiary GP 5, had significantly shorter times to disease recurrence. Univariate analysis demonstrated that primary GP 4 (P = 0.0003) and tertiary GP 5 (P < 0.0001) were strong predictors of disease recurrence. Primary GP 4 (P = 0.0122) remained an independent predictor of disease recurrence on stepwise multivariate analysis. CONCLUSIONS: Primary GP 4 tumors represented an aggressive subset of GS 7 prostate carcinomas. Primary GP was an easily accessible and clinically relevant predictor of disease recurrence in patients with GS 7 prostate carcinoma.