Proficiency score as a predictor of early trifecta achievement during the learning curve of robot-assisted radical prostatectomy for high-risk prostate cancer: Results of a multicentric series

Abstract

Background： Recently, an innovative tool called “proficiency score” was introduced to assess the learning curve for robot-assisted radical prostatectomy (RARP). However, the initial study only focused on patients with low-risk prostate cancer for whom pelvic lymph node dissection (PLND) was not required. To address this issue, we aimed to validate proficiency scores of a contemporary multicenter cohort of patients with high-risk prostate cancer treated with RARP plus extended PLND by trainee surgeons.

Material and methods: Between 2010 and 2020, 4 Italian institutional prostate-cancer datasets were merged and queried for “RARP” and “high-risk prostate cancer.” High-risk prostate cancer was defined according to the most recent European Association of Urology guidelines as follows: prostate-specific antigen >20 ng/mL, International Society of Urological Pathology ≥4, and/or clinical stage (cT) ≥ 2c on preoperative imaging. The selected cohort (n = 144) included clinical cases performed by trainee surgeons (n = 4) after completing their RARP learning curve (50 procedures for low-risk prostate cancer). The outcome of interest, the proficiency score, was defined as the coexistence of all the following criteria: a comparable operation time to the interquartile range of the mentor surgeon at each center, absence of any significant perioperative complications Clavien-Dindo Grade 3-5, no perioperative blood transfusions, and negative surgical margins. A logistic binary regression model was built to identify the predictors of 1-year trifecta achievement in the trainee cohort. For all statistical analyses, a 2-sided p < 0.05 was considered significant.

Results: A proficiency score was achieved in 42.3% patients. At univariable level, proficiency score was associated with 1-year trifecta achievement (odds ratio, 8.77; 95% confidence interval, 2.42-31.7; p = 0.001). After multivariable adjustments for age, nerve-sparing, and surgical technique, the proficiency score independently predicted 1-year trifecta achievement (odds ratio, 9.58; 95% confidence interval, 1.83-50.1; p = 0.007).

Conclusions: Our findings support the use of proficiency scores in patients and require extended PLND in addition to RARP.

Keywords

Trifecta / Learning curve / Robot-assisted radical prostatectomy / High-risk prostate cancer

Author summay

Umberto Anceschi and Rocco Simone Flammia equally contributed to the current study.

Supplemental Digital Content is available for this article.

Acknowledgments

None.

Statement of ethics

This study was conducted in accordance with the ethical principles of the Declaration of Helsinki and was approved by the Institutional Review Board of IRCCS “Regina Elena” National Cancer Institute. A waiver of informed consent was obtained, given the retrospective nature of the study.

Conflict of interest statement

The authors declare that they have no conflicts of interest.

Funding source

None.

Author contributions

All authors listed gave a substantive contribution to this study and to this original article.

UA, RSF: Conceptualization, writing—original draft preparation;

RSF, AT, MM: conceptualization, formal analysis and investigation;

IS: Statistical analysis;

AG, LGL, LM, PD, GT, AB, MCF, AMB, RM, GP, DM, TC, SS: Methodology;

UA, RSF: Conceptualization;

UA, AT, FP, EDT: Writing—review and editing;

AMB, GS: Project development.

Data availability

The datasets generated during and/or analyzed during the current study are not publicly available, but are available from the corresponding author on reasonable request.

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