Robot-Assisted Radical Prostatectomy (RARP) Trifecta Learning Curve for Surgeons with Previous Experience in Laparoscopy

Robot-assisted radical prostatectomy (RARP) is a complex surgery with a steep learning curve (LC). No clear evidence exists for how previous laparoscopic experience affects the RARP LC. We report the LC of three surgeons with vast experience in laparoscopy (more than 400 procedures), analyzing the results of functional and oncological outcomes under the "Trifecta" concept (defined as the achievement of continence, potency, and oncological control free of biochemical recurrence). The surgical experience of the three surgeons from September 2021 to December 2022, involving 146 RARP consecutive patients in a single institution center, was evaluated prospectively. Erectile disfunction patients were excluded. ANOVA and chi-square test were used to compare the distribution of variables between the three surgeons. LC analysis was performed using the cumulative sum control chart (CUSUM) technique to achieve trifecta. The median age was 65.42 (±7.34); the clinical stage were T1c (68%) and T2a (32%); the biopsy grades were ISUP 1 (15.9%), ISUP 2 (47.98), and ≥ISUP 3 (35%). The median surgical time was 132.8 (±32.8), and the mean intraoperative bleeding was 186 cc (±115). Complications included the following: Clavien-Dindo I 8/146 (5.47%); II 9/146 (6.16%); and III 3/146 (2.05%). Positive margins were reported in 44/146 (30.13%). The PSA of 145/146 patients (99%) at 6 months was below 0.08. Early continence was achieved in 101/146 (69.17%), 6-month continence 126/146 (86%), early potency 51/146 (34.9%), and 6-month potency 65/146 (44%). Surgeons "a", "b", and "c" performed 50, 47, and 49 cases, respectively. After CUSUM analysis, the "Trifecta" LC peak was achieved at case 19 in surgeon "a", 21 in surgeon "b", and 20 in surgeon "c". Conclusions: RARP LC to accomplish "Trifecta" can be significantly reduced in surgeons with previous experience in laparoscopy and be achieved at around 20 cases.