The influence of proficiency-based progression training on peri-operative and survival outcomes in robot-assisted laparoscopic surgery for endometrial cancer: an observational cohort study.

Abstract

Background: In the last years, the preferred approach in minimally-invasive surgery has shifted from straight-stick to robotic due to more precision, better views, reduced patient morbidity and improved surgeon ergonomics, which are especially beneficial in the increasing number of obese patients with endometrial cancer. An increased number of gynaecological oncology surgical fellowship programs have adopted robot-assisted laparoscopic (RAL) surgery as part of their training. SERGS and BIARGS developed proficiency-based progression (PBP) training curricula, but their effects on peri-operative and survival outcomes in endometrial cancer patients has not been assessed.

The Royal Marsden Hospital is a tertiary cancer centre in the United Kingdom (UK) treating high-risk endometrial cancer patients and has been training subspecialty trainees in gynaecological oncology in RAL surgery since 2015 in a PBP training manner.

Aim: To assess the influence of PBP training in RAL surgery for endometrial cancer on peri-operative and survival outcomes.

Methods: This is an observational cohort study. All women with primary endometrial cancer treated with RAL surgery between 2015 and 2022 were included. PBP training cases were identified pre-operatively by consultant surgeons based on clinical factors, such as BMI and comorbidities, and case complexity matching the experience of the trainee. Main outcome measures were intra- and post-operative complications, blood transfusions, readmissions < 30 days, return to theatre and 5-year disease-free and disease-specific survival for training versus non-training cases. Mann-Witney U, Pearson’s chi-squared and multivariable regression analysis was performed to assess the effect of PBP training on post-operative outcomes. Survival analysis was performed using Kaplan-Meier and Cox proportional hazard analysis.

Results: Training cases had a lower BMI than non-training cases (30 versus 32 kg/m2), but were comparable in age, performance status and comorbidities. Training had no influence on intra- and post-operative complications, blood transfusions, readmissions < 30 days and return to theatre rates. Operating time was longer in training cases (161 versus 137 min). Estimated blood loss, conversion rates, CCU-admissions and lymphoedema rates were comparable. No effect of training on 5-year disease-free and disease-specific survival was found.

Conclusions: Proficiency based progression training can be safely used to teach RAL surgery for women with endometrial cancer. Prospective trails are needed to further investigate the influence of distinct parts of RAL surgery performed by a trainee on endometrial cancer outcomes.