Assessing the learning curve for prostate cancer surgery

The idea that surgeon’s results improve with experience – a surgical learning curve – is commonly accepted. However, there have been very few studies empirically demonstrating a learning curve. We studied more than 10,000 prostate cancer patients from nine institutions who were treated by either open or laparoscopic radical prostatectomy. For open surgeries, increasing surgeon experience was associated with a dramatic decrease in the risk of recurrence up to about 250 operations. The learning curve was similar in magnitude for laparoscopic surgery, although it was somewhat slower, with 750 operations required for a comparable improvement in outcome. Fellowship training and prior open experience in laparoscopic surgeons both proved to be significant modifiers of the surgical learning curve: Only surgeons with fellowship training experienced an improvement in outcome with increasing experience; surgeons with open surgery experience conducting laparoscopic operations had poorer outcomes than those whose first operation was laparoscopic. The learning curve was seen for patients with both organ-confined and locally advanced tumors; excellent rates of cancer control for patients with organ-confined disease treated by the most experienced surgeons suggest that the primary reason such patients recur is inadequate surgical technique. Our experience with learning curves has taught us several key methodologic considerations for future learning curve research. The existence of the surgical learning curve poses a number of challenges to the surgical community, including questions of research, education, and clinical practice.