Prospective evaluation of learning curve for laparoscopic radical prostatectomy: Identification of factors improving operative times

Objectives. To evaluate the time required for each component of laparoscopic radical prostatectomy (LRP) performed by a single surgeon to identify the factors that expedite the learning curve. LRP is a technically demanding procedure with a lengthy learning curve. Methods. The LRP procedure was divided into 12 steps, and the time for each step was prospectively recorded during the first 50 consecutive patients undergoing LRP by a single surgeon. The operations were divided into five groups of 10, and the average times for each step were compared and correlated with surgeon observations and changes in surgical technique. Results. Statistically significant progressive improvement was seen in the total time of the LRP procedure (269.4 minutes in period 1 versus 205.4 minutes in period 4, P <0.05). Regarding the specific steps, improvement occurred in the time needed for dissection of the vas deferens and seminal vesicles (51.8 minutes for period 1 versus 25.3 minutes for period 4, P <0.01 and 31.2 minutes for period 5, P <0.03), apical incision (16.7 minutes for period 1 versus 6.3 minutes for period 4, P <0.03 and 5.7 minutes for period 5, P <0.02), and division of the rectourethralis (13.5 minutes for period 1 versus 3.4 minutes for period 5, P <0.05). The time needed for vesicourethral anastomosis remained unchanged throughout the study (average 48.5 minutes). Conclusions. With experience, the operative times for defined components of LRP improve. Patient selection for a low body mass index and smaller prostate may expedite the procedure. Application of a fixed retractor system, early identification of the vas deferens beneath the peritoneum in a more lateral position, and slow meticulous dissection and ligation of the dorsal vein complex are factors that may expedite the learning curve for LRP.