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THE UK'S FIRST 1,000 CASES OF LAPAROSCOPIC RADICAL PROSTATECTOMY: EVIDENCE OF MULTIPLE LEARNING CURVES
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381
THE ADVANCED LEARNING CURVE IN ROBOTIC PROSTATECTOMY: A MULTI-INSTITUTIONAL SURVEY
ROBOT ASSISTED LAPAROSCOPIC PROSTATECTOMY: A SINGLE INSTITUTION’S LEARNING CURVE
Palmer J., Dangle P., Patil N., Coughlin G., Patel V.R.
-DᚎH-, Barret E., Castellucci S., Cathelineau X., Rozet R., Galiano G., Vallancien V.
The Ohio State University, Centre for Robotic and Computer Assisted Surgery, Division of Urology, Columbus, United States of America Introduction & Objectives: 6HYHUDOVWXGLHVKDYHDWWHPSWHGWRGHᚏQHWKHOHDUQLQJ curve associated with robotic-assisted laparoscopic prostatectomy (RALP). These studies have focused on the acquisition of skills in novice robotic surgeons. Basic SURᚏFLHQF\ KRZHYHU FDQQRW EH HTXDWHG ZLWK VDWLVIDFWRU\ SDWLHQW RXWFRPHV :H surveyed experienced robotic surgeons with high surgical volume in an attempt to GHᚏQHDQಯDGYDQFHGರOHDUQLQJFXUYHUHODWLQJWRSURᚏFLHQF\DQGRXWFRPHVZLWKWKH robotic procedure. We report the results of a multi-institutional survey. Material & Methods: A questionnaire was designed at the Ohio State University to evaluate the learning curve of the RALP from basic to advanced techniques. High volume, experienced surgeons were asked to complete this evaluation based upon their personal experience with the RALP procedure. Questions included the overall number of RALP procedures performed, average operative time and the number RIFDVHVUHTXLUHGIRUSURᚏFLHQF\)XUWKHUTXHVWLRQVDVVHVVHGWKHQXPEHURIFDVHV XQWLOWKHVXUJHRQVZHUHVDWLVᚏHGZLWKWKHLURXWFRPHVUHJDUGLQJVXUJLFDOPDUJLQV potency and continence. Results: Nine institutions participated in the study accounting for a total case YROXPHRI0HGLDQVXUJHRQH[SHULHQFHZDVFDVHV 5DQJH median total operative and robotic time were 165 and 105 minutes, respectively. 0HGLDQWLPHWRಯEDVLFSURᚏFLHQF\ರZLWKWKHURERWZDVFDVHV PRUHFKDOOHQJLQJ cases were approached after a median of 50 cases. Surgical outcomes were deemed satisfactory to the surgeon for continence, potency and surgical margins DIWHUDPHGLDQRIDQGSURFHGXUHVUHVSHFWLYHO\ Conclusions: 7KLVGDWDFRQᚏUPVSUHYLRXVVWXGLHVWKDWEDVLFSURᚏFLHQF\ZLWKWKH robot occurs relatively quickly, after 40 cases. Obtaining “satisfactory outcomes”, KRZHYHUWRRNVXEVWDQWLDOO\ORQJHUIURPWRFDVHV6DWLVIDFWRU\RXWFRPHV regarding potency and surgical margins took longer to obtain than continence, UHᚐHFWLQJWKHUHODWLYHFRPSOH[LW\RIFDQFHUFRQWURODQGQHUYHVSDULQJFRPSDUHGWR the vesico-urethral anastomosis
Institut Montsouris, Dept. of Urology, Paris, France Introduction & Objectives: To evaluate the learning curve in performing a robot assisted laparoscopic prostatectomy (RALP) at a high volume laparoscopic radical prostatectomy centre. Material & Methods: 2IFRQVHFXWLYHPHQZKRXQGHUZHQW5$/3EHWZHHQ0D\DQG2FWREHU SDWLHQWV KDG FRPSOHWH GDWD WKDW ZDV UHWURVSHFWLYHO\ UHYLHZHG 'DWD LQFOXGHG SUHRSHUDWLYH SDUDPHWHUV RI DJH 36$ DQG *OHDVRQ VFRUH RSHUDWLYH SDUDPHWHUV LQFOXGLQJ RSHUDWLYH GXUDWLRQ DQG EORRGORVV DQGSRVWRSHUDWLYHSDUDPHWHUVLQFOXGLQJGXUDWLRQRIKRVSLWDOL]DWLRQIROH\GXUDWLRQSDWKRORJLF stage with margin status and pathologic Gleason score. Results: 0HDQ RSHUDWLYH GXUDWLRQ ZDV s PLQ EORRG ORVV ZDV s PO KRVSLWDO GXUDWLRQ was 5 days and age was 61 years for the entire study population. Operative time showed there was VWDWLVWLFDOO\VLJQLᚏFDQWGHFOLQHLQRSHUDWLYHWLPHDWWZRGLᚎHUHQWEUHDNSRLQWV7KHᚏUVWZDVDIWHUFDVHV DQGWKHVHFRQGDIWHU FDVHVZKLFKGLYLGHGWKHFRKRUWRISDWLHQWVLQWRJURXSV25WLPHIRUWKHWKUHH JURXSV ZDV s PLQ s PLQ DQG s PLQ IRU HDFK JURXS UHVSHFWLYHO\ VWDWLVWLFDOO\ VLJQLᚏFDQWDWWKHS OHYHOEHWZHHQWKHᚏUVWWZRJURXSVDQGEHWZHHQWKHVHFRQGDQGWKLUGJURXSV Margin status was analyzed by stage, and further subcategorized into the three groups: Overall Margins + 25 217 65 20
Nb Pts 42 (19%) 12 (18%) 4 (20%) 67 (19%)
First Group Margins Nb Pts + 0 (0%) 5 1 1(100%) 0 0(0%) 12 7(58%)
Second Group Margins Nb Pts + 19 5(1%) 12 107 9 1(11%) 177 45(25%)
Third Group Margins +
Nb Pts P2Ta
8 10 105 11 168
P2Tb pT2c S7D S7E All
0(0%) 1(10%) 8(8%) 7(20%) 19(11%)
3RVLWLYHPDUJLQUDWHLQWKHᚏUVWFDVHVZDVWKHVHFRQGJURXSZDVZKLFKGURSSHGWR LQ WKH WKLUG JURXS ZKLFK ZDV VWDWLVWLFDOO\ VLJQLᚏFDQW ZLWK S EHWZHHQ WKH ᚏUVW WZR JURXSV DQG S EHWZHHQWKHVHFRQGJURXSV)ROH\FDWKHWHUGXUDWLRQZDVDOVRVWDWLVWLFDOO\VLJQLᚏFDQWEHWZHHQWKH WKUHHJURXSV S S $JH S SUHRSHUDWLYH*OHDVRQ S DQG36$ S ZHUHVWDWLVWLFDOO\VLJQLᚏFDQWEHWZHHQWKHVHFRQGDQGWKLUGJURXSV+RZHYHUEORRGORVVSRVWRSHUDWLYH *OHDVRQVFRUHDQGOHQJWKRIKRVSLWDOVWD\GLGQRWGHPRQVWUDWHVWDWLVWLFDOVLJQLᚏFDQFHEHWZHHQWKHWKUHH groups. Conclusions: 8URORJLVWV ZKR DUH SURᚏFLHQW LQ ODSDURVFRSLF UDGLFDO SURVWDWHFWRP\ ZLOO VWLOO KDYH D OHDUQLQJ FXUYH ZKHQ ᚏUVW SHUIRUPLQJ D 5$/3 ([SHULHQFHG ODSDURVFRSLF VXUJHRQV GHPRQVWUDWHG continued improvement in operative and pathologic parameters with regard to operative duration and positive margin rate as their experience grows.
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THE IMPACT OF LAPAROSCOPIC EXPERIENCE ON OPEN SURGICAL TECHNIQUE AND SURGEON’S CONFIDENCE
THE UK’S FIRST 1,000 CASES OF LAPAROSCOPIC RADICAL PROSTATECTOMY: EVIDENCE OF MULTIPLE LEARNING CURVES
Gozen A.S.1, Teber D.1, Cresswell J.2, Ganta S.1, Canda A.1, Rassweiler J.1
Eden C.G., Chabert C.C., Neill M.G.
1
2
Clinic Heilbronn, Dept. of Urology, Heilbronn, Germany, James Cook University Hospital, Dept. of Urology, Middlesbrough, United Kingdom Introduction & Objectives: Anecdotally, laparoscopic surgeons report improved understanding of anatomical structures which may indirectly improve their open VXUJLFDOWHFKQLTXH7KHHᚎHFWRIDQLQWHQVLYHWUDLQLQJSURJUDPPHRQODSDURVFRSLF VXUJLFDO VNLOOV LV ZHOO GRFXPHQWHG +RZHYHU WKH HᚎHFW RI ODSDURVFRSLF WUDLQLQJ on open operative skills has not yet been evaluated. In our study we assess the impact of a structured laparoscopic training programme on the open surgical skills of trainees. Material & Methods: Over 100 trainees from 4 continents have been trained by our laparoscopic training programme over the last 5 years. Most of them regularly perform open surgical procedures at their home units. A straightforward online questionnaire was developed and our former training programme participants were contacted and invited to complete the questionnaire on an internet site. 7KH TXHVWLRQQDLUH DVNHG SUHGRPLQDQWO\ DERXW FRQᚏGHQFH GXULQJ RSHQ XURORJLFDO operations and trainees perceptions of their surgical skills. Results: The online questionnaires were completed by 41 out of 101 urologists contacted (response rate 40.6%). The majority (97 %) of responders felt there was DSRVLWLYHHᚎHFWRIODSDURVFRSLFWUDLQLQJRQWKHLURSHQVXUJLFDOVNLOOV:HIRXQGWKDW RIUHVSRQGHUVH[SHULHQFHGSRVLWLYHHᚎHFWVLQWHUPVRILQFUHDVHGFRQᚏGHQFH SUHFLVLRQ DQG FDUHIXO GLVVHFWLRQ GXULQJ WKH VWHSV RI RSHQ operations corresponding to their laparoscopic experience. 94 % of respondent WUDLQHHVUHSRUWHGWKDWWKH\IHOWPRUHFRQᚏGHQWJHQHUDOO\LQLGHQWLI\LQJDQDWRPLFDO ODQGPDUNVDQGRSHUDWLYHKDQGOLQJRIVWUXFWXUHV7KHJUHDWHVWLQFUHDVHLQFRQᚏGHQFH UDWHV ZDV UHSRUWHG LQ LGHQWLᚏFDWLRQ KDQGOLQJ DQG GLVVHFWLRQ RI QHXURYDVFXODU bundles during radical prostatectomy. The greatest improvement in subjective performance was reported for the nerve sparing procedure. Conclusions: 7KHVH GDWD GHPRQVWUDWH WKDW DPRQJ RWKHU EHQHᚏWV ODSDURVFRSLF WUDLQLQJFDQLQFUHDVHVXUJHRQFRQᚏGHQFHZLWKFRQFRPLWDQWLPSURYHPHQWLQRSHQ surgical skills.
Eur Urol Suppl 2008;7(3):166
The Royal Surrey County Hospital, Dept. of Urology, Guildford, United Kingdom Introduction & Objectives: Laparoscopic radical prostatectomy (LRP) is now a well-established minimal access alternative to open radical prostatectomy (ORP). 7KHOHDUQLQJFXUYHIRUWKLVSURFHGXUHKDVYDULRXVO\EHHQUHSRUWHGDVEHLQJ cases but logic dictates that as some aspects of the procedure are more technically challenging than others and that more than one learning curve exists. Material & Methods: Between March 2000 and November 2007 1, 000 consecutive SDWLHQWV ZLWK FOLQLFDO VWDJH 7ืD10 SURVWDWH FDQFHU XQGHUZHQW /53 HLWKHU supervised (16%) or performed (84%) by a single surgeon. The median PSA was 7.0 (1-50 ng/ml) and median Gleason sum was 6 (4-10). Clinical stage was T1 in 7LQ DQG7LQ Results: The median (with range) operating time was 177 (78-600) minutes. There ZDVDVLQJOHFRQYHUVLRQ SDWLHQW 7KHPHGLDQEORRGORVVZDV PO and four patients were transfused (0.4%). The median post-operative hospital stay ZDV QLJKWV 7KH PHGLDQ FDWKHWHULVDWLRQ WLPH ZDV GD\V 7KHUH ZHUH FRPSOLFDWLRQV UHTXLULQJ VXUJLFDO LQWHUYHQWLRQ LQ patients (58% of these as a day case admission). The positive margin rates according WRGಬ$PLFRULVNJURXSVZHUH ORZ LQWHUPHGLDWH DQGKLJK RISDWLHQWVKDGD36$RIืPJODWPRQWKV$WDPHDQIROORZXSRI (1-72) months 94.9% patients were pad-free, 65.6% who had both neurovascular bundles preserved had erections, and 96.1% were free of biochemical recurrence. Conclusions: The learning curve for operating time, blood transfusion and KRVSLWDOLVDWLRQZDVRYHUFRPHZLWKLQWKHᚏUVWFDVHVEXWFRPSOLFDWLRQFRQWLQHQFH and positive margin rates took >100 cases to plateau. The longest learning curve was for potency, which did not stabilise until after 500 cases. These learning curves are likely to be considerably shorter when surgeons are taught in departments with a high throughput of cases but both surgeons and patients need to be aware of WKHP,QYLHZRIRXUᚏQGLQJVZHUHFRPPHQGWKDW/53VKRXOGQRWEHVHOIWDXJKWEXW learned within an immersion teaching program. Even then, a large surgical volume is likely to be needed to maintain clinical outcomes at the highest level.
381
THE ADVANCED LEARNING CURVE IN ROBOTIC PROSTATECTOMY: A MULTI-INSTITUTIONAL SURVEY
ROBOT ASSISTED LAPAROSCOPIC PROSTATECTOMY: A SINGLE INSTITUTION’S LEARNING CURVE
Palmer J., Dangle P., Patil N., Coughlin G., Patel V.R.
-DᚎH-, Barret E., Castellucci S., Cathelineau X., Rozet R., Galiano G., Vallancien V.
The Ohio State University, Centre for Robotic and Computer Assisted Surgery, Division of Urology, Columbus, United States of America Introduction & Objectives: 6HYHUDOVWXGLHVKDYHDWWHPSWHGWRGHᚏQHWKHOHDUQLQJ curve associated with robotic-assisted laparoscopic prostatectomy (RALP). These studies have focused on the acquisition of skills in novice robotic surgeons. Basic SURᚏFLHQF\ KRZHYHU FDQQRW EH HTXDWHG ZLWK VDWLVIDFWRU\ SDWLHQW RXWFRPHV :H surveyed experienced robotic surgeons with high surgical volume in an attempt to GHᚏQHDQಯDGYDQFHGರOHDUQLQJFXUYHUHODWLQJWRSURᚏFLHQF\DQGRXWFRPHVZLWKWKH robotic procedure. We report the results of a multi-institutional survey. Material & Methods: A questionnaire was designed at the Ohio State University to evaluate the learning curve of the RALP from basic to advanced techniques. High volume, experienced surgeons were asked to complete this evaluation based upon their personal experience with the RALP procedure. Questions included the overall number of RALP procedures performed, average operative time and the number RIFDVHVUHTXLUHGIRUSURᚏFLHQF\)XUWKHUTXHVWLRQVDVVHVVHGWKHQXPEHURIFDVHV XQWLOWKHVXUJHRQVZHUHVDWLVᚏHGZLWKWKHLURXWFRPHVUHJDUGLQJVXUJLFDOPDUJLQV potency and continence. Results: Nine institutions participated in the study accounting for a total case YROXPHRI0HGLDQVXUJHRQH[SHULHQFHZDVFDVHV 5DQJH median total operative and robotic time were 165 and 105 minutes, respectively. 0HGLDQWLPHWRಯEDVLFSURᚏFLHQF\ರZLWKWKHURERWZDVFDVHV PRUHFKDOOHQJLQJ cases were approached after a median of 50 cases. Surgical outcomes were deemed satisfactory to the surgeon for continence, potency and surgical margins DIWHUDPHGLDQRIDQGSURFHGXUHVUHVSHFWLYHO\ Conclusions: 7KLVGDWDFRQᚏUPVSUHYLRXVVWXGLHVWKDWEDVLFSURᚏFLHQF\ZLWKWKH robot occurs relatively quickly, after 40 cases. Obtaining “satisfactory outcomes”, KRZHYHUWRRNVXEVWDQWLDOO\ORQJHUIURPWRFDVHV6DWLVIDFWRU\RXWFRPHV regarding potency and surgical margins took longer to obtain than continence, UHᚐHFWLQJWKHUHODWLYHFRPSOH[LW\RIFDQFHUFRQWURODQGQHUYHVSDULQJFRPSDUHGWR the vesico-urethral anastomosis
Institut Montsouris, Dept. of Urology, Paris, France Introduction & Objectives: To evaluate the learning curve in performing a robot assisted laparoscopic prostatectomy (RALP) at a high volume laparoscopic radical prostatectomy centre. Material & Methods: 2IFRQVHFXWLYHPHQZKRXQGHUZHQW5$/3EHWZHHQ0D\DQG2FWREHU SDWLHQWV KDG FRPSOHWH GDWD WKDW ZDV UHWURVSHFWLYHO\ UHYLHZHG 'DWD LQFOXGHG SUHRSHUDWLYH SDUDPHWHUV RI DJH 36$ DQG *OHDVRQ VFRUH RSHUDWLYH SDUDPHWHUV LQFOXGLQJ RSHUDWLYH GXUDWLRQ DQG EORRGORVV DQGSRVWRSHUDWLYHSDUDPHWHUVLQFOXGLQJGXUDWLRQRIKRVSLWDOL]DWLRQIROH\GXUDWLRQSDWKRORJLF stage with margin status and pathologic Gleason score. Results: 0HDQ RSHUDWLYH GXUDWLRQ ZDV s PLQ EORRG ORVV ZDV s PO KRVSLWDO GXUDWLRQ was 5 days and age was 61 years for the entire study population. Operative time showed there was VWDWLVWLFDOO\VLJQLᚏFDQWGHFOLQHLQRSHUDWLYHWLPHDWWZRGLᚎHUHQWEUHDNSRLQWV7KHᚏUVWZDVDIWHUFDVHV DQGWKHVHFRQGDIWHU FDVHVZKLFKGLYLGHGWKHFRKRUWRISDWLHQWVLQWRJURXSV25WLPHIRUWKHWKUHH JURXSV ZDV s PLQ s PLQ DQG s PLQ IRU HDFK JURXS UHVSHFWLYHO\ VWDWLVWLFDOO\ VLJQLᚏFDQWDWWKHS OHYHOEHWZHHQWKHᚏUVWWZRJURXSVDQGEHWZHHQWKHVHFRQGDQGWKLUGJURXSV Margin status was analyzed by stage, and further subcategorized into the three groups: Overall Margins + 25 217 65 20
Nb Pts 42 (19%) 12 (18%) 4 (20%) 67 (19%)
First Group Margins Nb Pts + 0 (0%) 5 1 1(100%) 0 0(0%) 12 7(58%)
Second Group Margins Nb Pts + 19 5(1%) 12 107 9 1(11%) 177 45(25%)
Third Group Margins +
Nb Pts P2Ta
8 10 105 11 168
P2Tb pT2c S7D S7E All
0(0%) 1(10%) 8(8%) 7(20%) 19(11%)
3RVLWLYHPDUJLQUDWHLQWKHᚏUVWFDVHVZDVWKHVHFRQGJURXSZDVZKLFKGURSSHGWR LQ WKH WKLUG JURXS ZKLFK ZDV VWDWLVWLFDOO\ VLJQLᚏFDQW ZLWK S EHWZHHQ WKH ᚏUVW WZR JURXSV DQG S EHWZHHQWKHVHFRQGJURXSV)ROH\FDWKHWHUGXUDWLRQZDVDOVRVWDWLVWLFDOO\VLJQLᚏFDQWEHWZHHQWKH WKUHHJURXSV S S $JH S SUHRSHUDWLYH*OHDVRQ S DQG36$ S ZHUHVWDWLVWLFDOO\VLJQLᚏFDQWEHWZHHQWKHVHFRQGDQGWKLUGJURXSV+RZHYHUEORRGORVVSRVWRSHUDWLYH *OHDVRQVFRUHDQGOHQJWKRIKRVSLWDOVWD\GLGQRWGHPRQVWUDWHVWDWLVWLFDOVLJQLᚏFDQFHEHWZHHQWKHWKUHH groups. Conclusions: 8URORJLVWV ZKR DUH SURᚏFLHQW LQ ODSDURVFRSLF UDGLFDO SURVWDWHFWRP\ ZLOO VWLOO KDYH D OHDUQLQJ FXUYH ZKHQ ᚏUVW SHUIRUPLQJ D 5$/3 ([SHULHQFHG ODSDURVFRSLF VXUJHRQV GHPRQVWUDWHG continued improvement in operative and pathologic parameters with regard to operative duration and positive margin rate as their experience grows.
382
383
THE IMPACT OF LAPAROSCOPIC EXPERIENCE ON OPEN SURGICAL TECHNIQUE AND SURGEON’S CONFIDENCE
THE UK’S FIRST 1,000 CASES OF LAPAROSCOPIC RADICAL PROSTATECTOMY: EVIDENCE OF MULTIPLE LEARNING CURVES
Gozen A.S.1, Teber D.1, Cresswell J.2, Ganta S.1, Canda A.1, Rassweiler J.1
Eden C.G., Chabert C.C., Neill M.G.
1
2
Clinic Heilbronn, Dept. of Urology, Heilbronn, Germany, James Cook University Hospital, Dept. of Urology, Middlesbrough, United Kingdom Introduction & Objectives: Anecdotally, laparoscopic surgeons report improved understanding of anatomical structures which may indirectly improve their open VXUJLFDOWHFKQLTXH7KHHᚎHFWRIDQLQWHQVLYHWUDLQLQJSURJUDPPHRQODSDURVFRSLF VXUJLFDO VNLOOV LV ZHOO GRFXPHQWHG +RZHYHU WKH HᚎHFW RI ODSDURVFRSLF WUDLQLQJ on open operative skills has not yet been evaluated. In our study we assess the impact of a structured laparoscopic training programme on the open surgical skills of trainees. Material & Methods: Over 100 trainees from 4 continents have been trained by our laparoscopic training programme over the last 5 years. Most of them regularly perform open surgical procedures at their home units. A straightforward online questionnaire was developed and our former training programme participants were contacted and invited to complete the questionnaire on an internet site. 7KH TXHVWLRQQDLUH DVNHG SUHGRPLQDQWO\ DERXW FRQᚏGHQFH GXULQJ RSHQ XURORJLFDO operations and trainees perceptions of their surgical skills. Results: The online questionnaires were completed by 41 out of 101 urologists contacted (response rate 40.6%). The majority (97 %) of responders felt there was DSRVLWLYHHᚎHFWRIODSDURVFRSLFWUDLQLQJRQWKHLURSHQVXUJLFDOVNLOOV:HIRXQGWKDW RIUHVSRQGHUVH[SHULHQFHGSRVLWLYHHᚎHFWVLQWHUPVRILQFUHDVHGFRQᚏGHQFH SUHFLVLRQ DQG FDUHIXO GLVVHFWLRQ GXULQJ WKH VWHSV RI RSHQ operations corresponding to their laparoscopic experience. 94 % of respondent WUDLQHHVUHSRUWHGWKDWWKH\IHOWPRUHFRQᚏGHQWJHQHUDOO\LQLGHQWLI\LQJDQDWRPLFDO ODQGPDUNVDQGRSHUDWLYHKDQGOLQJRIVWUXFWXUHV7KHJUHDWHVWLQFUHDVHLQFRQᚏGHQFH UDWHV ZDV UHSRUWHG LQ LGHQWLᚏFDWLRQ KDQGOLQJ DQG GLVVHFWLRQ RI QHXURYDVFXODU bundles during radical prostatectomy. The greatest improvement in subjective performance was reported for the nerve sparing procedure. Conclusions: 7KHVH GDWD GHPRQVWUDWH WKDW DPRQJ RWKHU EHQHᚏWV ODSDURVFRSLF WUDLQLQJFDQLQFUHDVHVXUJHRQFRQᚏGHQFHZLWKFRQFRPLWDQWLPSURYHPHQWLQRSHQ surgical skills.
Eur Urol Suppl 2008;7(3):166
The Royal Surrey County Hospital, Dept. of Urology, Guildford, United Kingdom Introduction & Objectives: Laparoscopic radical prostatectomy (LRP) is now a well-established minimal access alternative to open radical prostatectomy (ORP). 7KHOHDUQLQJFXUYHIRUWKLVSURFHGXUHKDVYDULRXVO\EHHQUHSRUWHGDVEHLQJ cases but logic dictates that as some aspects of the procedure are more technically challenging than others and that more than one learning curve exists. Material & Methods: Between March 2000 and November 2007 1, 000 consecutive SDWLHQWV ZLWK FOLQLFDO VWDJH 7ืD10 SURVWDWH FDQFHU XQGHUZHQW /53 HLWKHU supervised (16%) or performed (84%) by a single surgeon. The median PSA was 7.0 (1-50 ng/ml) and median Gleason sum was 6 (4-10). Clinical stage was T1 in 7LQ DQG7LQ Results: The median (with range) operating time was 177 (78-600) minutes. There ZDVDVLQJOHFRQYHUVLRQ SDWLHQW 7KHPHGLDQEORRGORVVZDV PO and four patients were transfused (0.4%). The median post-operative hospital stay ZDV QLJKWV 7KH PHGLDQ FDWKHWHULVDWLRQ WLPH ZDV GD\V 7KHUH ZHUH FRPSOLFDWLRQV UHTXLULQJ VXUJLFDO LQWHUYHQWLRQ LQ patients (58% of these as a day case admission). The positive margin rates according WRGಬ$PLFRULVNJURXSVZHUH ORZ LQWHUPHGLDWH DQGKLJK RISDWLHQWVKDGD36$RIืPJODWPRQWKV$WDPHDQIROORZXSRI (1-72) months 94.9% patients were pad-free, 65.6% who had both neurovascular bundles preserved had erections, and 96.1% were free of biochemical recurrence. Conclusions: The learning curve for operating time, blood transfusion and KRVSLWDOLVDWLRQZDVRYHUFRPHZLWKLQWKHᚏUVWFDVHVEXWFRPSOLFDWLRQFRQWLQHQFH and positive margin rates took >100 cases to plateau. The longest learning curve was for potency, which did not stabilise until after 500 cases. These learning curves are likely to be considerably shorter when surgeons are taught in departments with a high throughput of cases but both surgeons and patients need to be aware of WKHP,QYLHZRIRXUᚏQGLQJVZHUHFRPPHQGWKDW/53VKRXOGQRWEHVHOIWDXJKWEXW learned within an immersion teaching program. Even then, a large surgical volume is likely to be needed to maintain clinical outcomes at the highest level.