The learning curve for laparoscopic extended pelvic lymphadenectomy for intermediate‐ and high‐risk prostate cancer: implications for compliance with existing guidelines

• Published in: BJU international 2013-08, Vol.112 (3), p.346-354
• Main Authors: Eden, Christopher G., Zacharakis, Evangelos, Bott, Simon
• Format: Article
• Language: English
• Subjects: Adult; Aged; Biological and medical sciences; Compliance; Guideline Adherence; Gynecology. Andrology. Obstetrics; Humans; laparoscopy; Laparoscopy - education; Learning Curve; Lymph Node Excision - education; Lymph Node Excision - methods; Male; Male genital diseases; Medical sciences; Middle Aged; Nephrology. Urinary tract diseases; prostate cancer; Prostatectomy - methods; Prostatic Neoplasms - surgery; radical prostatectomy; Risk Assessment; Tumors; Tumors of the urinary system; Urinary tract. Prostate gland
• ISSN: 1464-4096; 1464-410X
• DOI: 10.1111/j.1464-410X.2012.11671.x

Objective To investigate the learning curve for performing extended pelvic lymphadenectomy (ePLND) during laparoscopic radical prostatectomy (LRP) in patients with intermediate‐ and high‐risk prostate cancer. Patients and methods In all, 500 patients underwent ePLND for intermediate‐ or high‐risk prostate cancer by one surgeon during a 48‐month period. A transperitoneal laparoscopic approach was used in all patients to allow adequate access to the internal iliac vessels. The variables chosen as being the most important discriminators of the quality of ePLND were operating time, complication rate and lymph node (LN) yield. The learning curves for ePLND were calculated using the cumulative sum and cumulative average methods and the number of procedures performed until attainment of acceptable failure rates (competence levels) was calculated. LN parameters were compared with the results from the preceding 311 cases where limited PLND was undertaken. Results The median (range) preoperative PSA level was 8.0(1–62.5) ng/mL and biopsy Gleason score was 7(6–10). In all, 64% of patients had intermediate‐risk and 36% had high‐risk prostate cancer. There were no intraoperative blood transfusions and no conversions to open surgery. The median (range) blood loss was 200(10–1400) mL and the postoperative transfusion rate was 1.6%. The operating time fell at a steady rate of 2.7% after the 15th case and plateaued after 130 patients. At competence levels of 5% and 10%, the learning curve for all complications ended after 346 and 136 patients, respectively. At a 5% competence level the learning curve for PLND‐specific complications was 40 cases and there was no learning curve at a 10% competence level. The overall complication rate was 7.2% of which almost half (47%) were deemed to be PLND‐specific. The cumulative average of the LN counts plateaued after 150 procedures. Furthermore, the median LN count after ePLND was more than double that of the authors' historical standard PLND controls (14 vs 6, P