A Novel, Structured Fellow Training Pathway for Robotic-Assisted Sacrocolpopexy



 

Tatiana Catanzarite, MD, MAS1; Jasmine Tan-Kim, MD, MAS1; John N Nguyen, MD2; Sharon Jakus-Waldman, MD2; Shawn A Menefee, MD1

Perm J 2021;25:20.224

https://doi.org/10.7812/TPP/20.224
E-pub: 05/26/2021

ABSTRACT

Introduction: We developed a novel fellow education pathway for robotic-assisted sacrocolpopexy (RASC) and aimed to compare step-specific and total operative times for RASC performed by Female Pelvic Medicine and Reconstructive Surgery (FPMRS) attendings with those in which FPMRS fellows performed part or all of the RASC. We further aimed to compare complication and readmission rates by fellow involvement.

Methods: We tracked RASC at 1 institution between 2012 and 2018. We recorded times for total procedure, sacrocolpopexy, and 6 individual steps. Fellows were designated F1-F3 by training year. We used independent samples t-tests and analysis of variance for continuous variables and χ2 and Fisher’s exact tests for categorical variables.

Results: Of 178 RASC procedures, 76 (42.7%) involved fellows. Concomitant procedures included hysterectomy (62.4%), midurethral sling (50%), and colporrhaphy/perineorrhaphy (51.7%). RASC without and with fellows had similar demographic, clinical, and procedural characteristics, except for midurethral sling rate (attending, 42.2% vs fellow, 60.5%; p = 0.02). RASC without and with fellows had similar times for total procedure (208.9 ± 61.0 vs 209.1 ± 48.6 minutes, p = 0.98), sacrocolpopexy (116.9 ± 39.9 vs 122.7 ± 29.2 minutes, p = 0.27), and all RASC steps except docking (attendings, 9.9 ± 8.6 vs fellows, 7.2 ± 7.0 minutes; p = 0.03). Complication rates and severity were similar without and with fellows. There were no readmissions.

Discussion/Conclusion: Our novel structured training program provides safe limitations for total and step-specific procedural times during fellowship education in RASC. Such training programs warrant further study to determine potential contribution to quality and safety in the teaching environment.

INTRODUCTION

Abdominal sacrocolpopexy has emerged in systematic reviews as the gold standard for correction of apical prolapse.1 Advantages of minimally invasive sacrocolpopexy include decreased blood loss,2-5 less pain,6 and shorter hospital stay,3-5 while preserving excellent success rates and patient satisfaction.1,6 Conventional laparoscopic and robotic-assisted sacrocolpopexy (RASC) have similar outcomes and complication rates.6-8 Proposed benefits of robotics include improved ergonomics, 3-dimensional optics, instrument stabilization, and relative ease of suturing.6,9 Robotic assistance shortens surgeon learning curves,10-12 but up to 60 RASC procedures are still required for maximal efficiency.13,14 Because prolonged operative time in gynecologic surgery is associated with complications,15 surgical training must endeavor to maximize trainee participation for mastery of complex skills without sacrificing procedural efficiency or safety.

Unlike open surgery and conventional laparoscopy, the robotic operating platform allows only 1 surgeon to operate at a time, with surgeons separated by space and equipment and with senior surgeons less able to intervene.16,17 Despite widespread adoption of robotic surgery, robotic training is variable and largely unstructured.18 Experts recommend implementation of formal robotics training programs, including didactics, dry and wet lab simulation with specific instruction on docking, instrumentation, and console manipulation, case observation, and bedside assistance before console training in the operating room.9,17 Structured training protocols have been described for robotic-assisted Roux-en-Y gastric bypass19 and robot-assisted radical prostatectomy20; to our knowledge, ours is the first comprehensive training pathway developed for RASC.

We implemented a novel fellow education pathway consisting of 4 phases: 1) online and in-person da Vinci system training, videos, and online assessment (approximately 7 hours); 2) satisfactory completion (scores ≥ 75%) of 22 simulation modules; 3) bedside assistance during 3 RASC; and 4) console training in the operating room. During console training, the fellow must demonstrate safe and efficient performance of 5 steps: 1) hysterectomy, 2) vaginal dissection, 3) presacral dissection, 4) vaginal mesh attachment, and 5) sacral mesh attachment and reperitonealization. We calculated benchmark operative times from attending learning curve cases (first 62 RASC) to reflect realistic procedure times during skill acquisition. Fellows were designated F1-F3 according to year of training within the 3-year Female Pelvic Medicine and Reconstructive Surgery (FPMRS) program. Fellows participated in docking and port placement during all procedures. Cases were designated fellow RASC when the fellow operated as primary surgeon for part or all of the RASC. All procedures were performed using the single-console da Vinci platform, either Si or Xi; 2 attending surgeons were usually present, 1 providing bedside assistance and the other instructing the fellow. When needed, the latter switched positions with the fellow to operate at the console, as described below.

Our training pathway is illustrated in Figure 1. For each step, the fellow is allotted 20% longer-than-average attending time, after which the attending completes that step. The fellow may then resume operating, if appropriate for skill level. For junior fellows, the attending may use discretion to complete technically challenging steps before benchmark time is reached. If a complication occurs, the fellow may manage the complication if appropriate for skill level; if not, the attending manages the complication, after which the fellow resumes.

tpj20224f1

Figure 1. Structured fellow training pathway in robotic-assisted laparoscopic sacrocolpopexy. Female Pelvic Medicine and Reconstructive Surgery fellows move sequentially from phase 1 to phase 4. Phases 1 and 2 consist of training in the simulation setting, whereas phases 3 and 4 involve training in the operating room environment.

Our primary aim was to compare step-specific and total operative times for RASC performed by FPMRS attendings with those performed by FPMRS fellows within this novel, structured RASC training pathway. We further aimed to compare complications and readmissions by fellow involvement and fellow year, as well as operative times by fellow year. We hypothesized that there would be differences in RASC operative times based on fellow involvement and level of experience, but that these differences would not impact perioperative morbidity.

METHODS

An Institution Review Board–approved protocol was implemented at our institution at initiation of the robotics program (2012) to prospectively track operative times during consecutive RASC from 2012 to 2018. This was a substudy of a prospective observational study (clinicaltrials.gov identifier NCT01535833). RASC was performed by board-certified FPMRS attendings (n = 4) with or without FPMRS fellows (n = 7). Resident physicians did not perform any portion of RASC. All participants desiring RASC completed informed consent forms to participate in the study protocol.

Three attendings were experienced in laparoscopic sacrocolpopexy but novices in robotics; the fourth attending had completed robotic training during FPMRS fellowship. All attendings completed preconsole training (Figure 1) and proctoring of the first 5 cases. During RASC for uterovaginal prolapse, total or supracervical hysterectomy was performed; there were no hysteropexies. Vaginal mesh attachment was performed with interrupted monofilament delayed absorbable sutures and/or continuous barbed suture (V-Loc; Medtronic, Minneapolis, MN); when V-Loc was used, a minimum of 2 interrupted sutures were also placed. Sacral mesh attachment was performed with 2 to 3 monofilament permanent sutures. Reperitonealization of mesh and cystoscopy were performed in all cases.

We recorded times for the total procedure (incision to close, including concomitant procedures), sacrocolpopexy (start of anterior dissection to completion of reperitonealization), and 5 RASC steps: port placement (first incision until placement of last port), robot docking (placement of last port until all ports docked), vaginal dissection (start to completion of anterior and posterior dissection), sacral dissection (start to completion of sacral dissection with satisfactory exposure of anterior longitudinal ligament), and vaginal mesh attachment (placement of first suture to tying of last knot). Operative time for robotic hysterectomy (cauterization of first utero-ovarian ligament to amputation of specimen for supracervical or vaginal closure for total hysterectomy), when performed, was also recorded. Start and end times were documented intraoperatively by one of the attending surgeons. Sacral mesh attachment and reperitonealization were not timed to avoid pressuring the surgeon during sacral suturing; these were included in sacrocolpopexy time. When performed, lysis of adhesions was included in total procedure time and adnexectomy in either sacrocolpopexy or hysterectomy time, depending on exposure and timing.

Primary study outcomes were total and step-specific operative times for RASC with and without fellow involvement. Secondary outcomes included: 1) intraoperative complications, 90-day postoperative complications, and 30-day readmissions compared by fellow involvement and fellow year; and 2) total and step-specific operative times compared by fellow year. Participant characteristics, including demographics, comorbidities, surgical history, Charlson comorbidity index,21 and preoperative Pelvic Organ Prolapse Quantification examination (as defined by Bump et al22) were recorded.

Intraoperative and 90-day postoperative complications, as well as 30-day readmissions, were tracked. Urinary tract infection (UTI) was defined as positive urine culture treated with antibiotics or symptoms with empiric antibiotic treatment. Wound infection was defined as any incisional infection (abdominal, vaginal, or perineal) treated with antibiotics. Clavien-Dindo scores23 were assigned to postoperative complications.

Analyses were performed with χ2 and Fisher’s exact tests for categorical variables and independent samples t-test (2 groups) or one-way analysis of variance with post-hoc Bonferroni correction (≥ 3 groups) for continuous variables. Analyses were performed using SPSS, version 26 (Chicago, IL). Results are presented as mean ± standard deviation, unless otherwise indicated.

RESULTS

Operative times were recorded for 178 RASC procedures, of which 76 (42.7%) involved fellows. Concomitant procedures included robotic hysterectomy in 111 (62.4%) patients, the majority of which were supracervical (104/111, 93.7%); midurethral sling in 89 (50.0%); and colporrhaphy and/or perineorrhaphy in 92 (51.7%).

Most demographic, clinical, and procedural characteristics were similar for RASC with and without fellows (Table 1). The rate of prior incontinence surgery trended lower for fellow RASC (p = 0.05); rates of concomitant sling, placement of 3 sacral sutures, and V-Loc use were higher for fellow RASC. A median of 6.6 (range, 2-11) interrupted sutures were also placed in participants in whom V-Loc was used.

Table 1. Comparison of clinical characteristics for participants undergoing robotic-assisted sacrocolpopexy without and with Female Pelvic Medicine and Reconstructive Surgery fellow involvement

Characteristic No fellows Fellows p valuea
n = 102 n = 76
Age (y) 61.4 ± 9.5 61.7 ± 8.6 0.82
Parity (#) 2.6 ± 1.3 2.6 ± 1.3 0.81
Race/ethnicity      
White, % (#) 62.7 (64) 76.3 (58) 0.12
Hispanic, % (#) 31.4 (32) 17.1 (13)
African American, % (#) 0 0
Asian, % (#) 2.9 (3) 5.3 (4)
Pacific Islander, % (#) 2 (2) 0
Native American, % (#) 0 1.3 (1)
Other/declined, % (#) 1 (1) 0
BMI (kg/m2) 27.8 ± 4.7 27.4 ± 4.5 0.61
Smoking      
Never, % (#) 69.6 (71) 71.1 (54) 0.65
Former, % (#) 29.4 (30) 26.3 (20)
Current, % (#) 1 (1) 2.6 (2)
Charlson comorbidity indexb 0.6 ± 1.0 0.6 ± 0.9 0.76
Diabetes, % (#) 9.8 (10) 9.2 (7) 0.89
Chronic pulmonary disease, % (#) 10.8 (11) 15.8 (12) 0.33
Prior cesarean section, % (#) 6.9 (7) 5.3 (4) 0.76
Prior abdominal surgery, % (#) 66.0 (66) 61.3 (46) 0.52
Prior prolapse repair, % (#) 23.8 (24) 12.3 (9) 0.06
Prior incontinence surgery, % (#) 14.7 (15) 5.3 (4) 0.05
Preoperative Bac 2.5 ± 2.4 2.8 ± 2.4 0.29
Preoperative Cc −0.1 ± 4.0 0.3 ± 3.9 0.46
Preoperative Bpc −0.4 ± 3.0 0.1 ± 3.1 0.22
Anterior vaginal dissection (cm) 5.7 ± 1.3 5.6 ±1.1 0.45
Posterior vaginal dissection (cm) 8.7 ± 1.7 8.4 ± 1.3 0.11
Interrupted sutures placed (#) 11.7 ± 3.1 11.1 ± 3.4 0.52
Sacral sutures placed, % (#) 2: 98.0 (98) 2: 89.5 (68) 0.02
3: 2.0 (2) 3: 10.5 (8)
V-Loc suture used, % (#) 13.9 (14) 27.6 (21) 0.02
Robotic hysterectomy, % (#)d 59.8 (61) 65.8 (50) 0.42
Concomitant procedures, % (#)e 62.7 (64) 80.3 (61) 0.01
Midurethral sling, % (#) 42.2 (43) 60.5 (46) 0.02
Colporrhaphy/perineorrhaphy, % (#) 45.1 (46) 52.6 (40) 0.32

a. Comparisons performed with independent samples t-tests for continuous variables and χ2/Fisher’s exact tests for categorical variables.

b. Charlson comorbidity index calculated according to definitions by Charlson et al.21

c. Pelvic Organ Prolapse Quantification points Ba, C, and Bp as designated by Bump et al.22

d. Majority supracervical (104/111, 93.7%).

e. Concomitant procedures to robotic-assisted sacrocolpopexy included anterior colporrhaphy, posterior colporrhaphy, perineorrhaphy, and midurethral sling. Participants may have undergone one or multiple concomitant procedures. Adnexectomy procedures were not counted as separate/concomitant procedures.

BMI = body mass index.

Bold type indicates statistical significance.

As displayed in Table 2, RASC without and with fellows had similar times for total procedure (208.9 vs 209.1 minutes, p = 0.98), sacrocolpopexy (116.9 vs 122.7 minutes, p = 0.27), port placement (12.7 vs 11.1 minutes, p = 0.20), hysterectomy (38.6 vs 34.6 minutes, p = 0.37), vaginal dissection (24.4 vs 20.7 minutes, p = 0.13), sacral dissection (17.2 vs 18.5 minutes, p = 0.48), and vaginal mesh attachment (33.6 vs 35.8 minutes, p = 0.46). Docking was slightly faster with fellows (7.2 vs 9.9 minutes, p = 0.03).

Table 2. Comparison of operative times (average ± standard deviation) in minutes for each step of robotic-assisted laparoscopic sacrocolpopexy procedure by Female Pelvic Medicine and Reconstructive Surgery fellow involvement

Step of procedure No fellows, min Fellows, min p valuea
n = 102 n = 76
Total procedureb 208.9 ± 61.0 209.1 ± 48.6 0.98
Sacrocolpopexyc 116.9 ± 39.9 122.7 ± 29.2 0.27
Port placement 12.7 ± 9.3 11.1 ± 6.1 0.20
Robotic docking 9.9 ± 8.6 7.2 ± 7.0 0.03
Hysterectomy (n = 111)d 38.6 ± 24.1 34.6 ± 21.8 0.37
Vaginal dissection 24.4 ± 20.3 20.7 ± 11.5 0.13
Sacral dissection 17.2 ± 12.1 18.5 ± 11.1 0.48
Mesh attachment 33.6 ± 21.8 35.8 ±17.1 0.46

a. Comparisons performed with independent samples t-test.

b. Total procedure time defined as incision to closure, including any concomitant procedures.

c. Sacrocolpopexy time defined as start of anterior dissection to completion of reperitonealization.

d. Robotic-assisted hysterectomy, majority supracervical (104/111, 93.7%).

Bold type indicates statistical significance.

Sacrocolpopexy time and times for all sacrocolpopexy steps were similar across fellow years (Table 3). F2 fellows had the longest times for total procedure and port placement. Rates of concomitant sling (F1: 62.5%, F2: 57.1%, F3: 62.5%, p = 0.90) and colporrhaphy/perineorrhaphy (F1: 45.8%, F2: 60.7%, F3: 50.0%, p = 0.54) were similar for all fellow years, but there was a trend toward a higher hysterectomy rate for F2 (F1: 54.2%, F2: 82.1%, F3: 58.3%, p = 0.07).

Table 3. Comparison of operative times (average ± standard deviation) in minutes for each step of robotic-assisted laparoscopic sacrocolpopexy procedure, presented by Female Pelvic Medicine and Reconstructive Surgery fellow year of training

Step of procedure F1, mina F2, mina F3, mina Corrected p valueb
n = 24 n = 28 n = 24
Total procedurec 211.0 ± 51.6 224.4 ± 49.0 189.3 ± 39.3 F1 vs F2: 0.93
F2 vs F3: 0.03
F3 vs F1: 0.34
Sacrocolpopexyd 122.6 ± 25.7 124.1 ± 35.3 121.3 ± 26.4 F1 vs F2: 1
F2 vs F3: 1
F3 vs F1: 1
Port placement 10.8 ± 4.0 13.2 ± 8.0 9.0 ± 4.4 F1 vs F2: 0.49
F2 vs F3: 0.04
F3 vs F1: 0.85
Robotic docking 6.6 ± 1.6 8.6 ± 11.2 6.0 ± 2.7 F1 vs F2: 0.90
F2 vs F3: 0.57
F3 vs F1: 1
Hysterectomy (n = 50)e 33.2 ± 18.2 37.6 ± 28.9 31.1 ± 6.9 F1 vs F2: 1
F2 vs F3: 1
F3 vs F1: 1
Vaginal dissection 21.5 ± 12.8 20.3 ± 11.2 20.2 ± 10.9 F1 vs F2: 1
F2 vs F3: 1
F3 vs F1: 1
Sacral dissection 19.2 ± 14.7 17.4 ± 8.5 19.1 ± 10.2 F1 vs F2: 1
F2 vs F3: 1
F3 vs F1: 1
Mesh attachment 40.8 ± 23.7 36.1 ± 14.6 30.5 ± 9.0 F1 vs F2: 0.95
F2 vs F3: 0.72
F3 vs F1: 0.11

a. F1-F3: Female Pelvic Medicine and Reconstructive Surgery Fellow year 1, 2, and 3.

b. Comparisons performed with analysis of variance and post-hoc Bonferroni correction.

c. Total procedure time defined as incision to closure, including any concomitant procedures.

d. Sacrocolpopexy time, defined as start of anterior dissection to completion of reperitonealization.

e. Robotic-assisted hysterectomy, majority (48/50, 96%) supracervical.

Bold type indicates statistical significance.

Complications occurred in 20.8% of patients (37/178), with intraoperative injury in 3.4% (6/178) and 90-day postoperative complications in 18.5% (33/178). There were no 30-day readmissions. Intraoperative complications included bladder injury (n = 3, including 1 sling trocar perforation), bowel injury (n = 1, Kocher clamp grasp of bowel during specimen removal), and colpotomy (n = 2). Most postoperative complications comprised UTI (54.5%; 18/33) and wound infection (39.3%; 13/33; 7 abdominal, 2 suprapubic, 4 perineal); the mean Clavien-Dindo score was 2. Other 90-day complications included 1 case of syndrome of inappropriate antidiuretic hormone and 2 lower extremity neuropathies. There was 1 small bowel obstruction occurring 6 months postoperatively, which was managed surgically. As above, 5 of the 37 complications – including trocar cystotomy and suprapubic/perineorrhaphy infections – arose from concomitant procedures and not RASC itself.

RASC without and with fellows had similar rates of overall complications, intraoperative injury, 90-day postoperative complications, UTI, and wound infection (Table 4). Clavien-Dindo scores without and with fellows were comparable, again driven mostly by UTI and wound infection (both Clavien-Dindo = 2). There were no differences in complication rates or severity by fellow year (Table 5).

Table 4. Comparison of intraoperative injury, 90-day postoperative complications, and 30-day readmissions for robotic-assisted sacrocolpopexy procedures with and without Female Pelvic Medicine and Reconstructive Surgery fellow involvement

Type of complication No fellows Fellows p valuea
n = 102 n = 76
Any complication, % (#) 19.6 (20) 22.4 (17) 0.65
Intraoperative injury, % (#) 3.9 (4) 2.6 (2) 1
Postoperative complication < 90 d, % (#) 17.6 (18) 19.7 (15) 0.72
Clavien-Dindo scoreb 2.0 ± 0 2.0 ± 0.4 1
Urinary tract infection < 90 d, % (#) 10.8 (11) 9.2 (7) 0.73
Wound infection < 90 d, % (#) 7.8 (8) 6.6 (5) 0.75
Readmission < 30 d, % (#) 0 0 --

a. Comparisons performed with χ2/Fisher’s exact tests for categorical variables and independent samples t-test for continuous variables.

b. Clavien-Dindo score, as defined by Clavien et al,23 calculated and compared for participants with postoperative complications only.

Table 5. Comparison of intraoperative injury, 90-day postoperative complications, and readmission rates after robotic-assisted laparoscopic sacrocolpopexy procedures by Female Pelvic Medicine and Reconstructive Surgery fellow year

Type of complication F1 F2 F3 p valuea
n = 24 n = 28 n = 24
Any complication, % (#) 29.2 (7) 17.9 (5) 20.8 (5) 0.61
Intraoperative injury, % (#) 8.3 (2) 0 0 0.11
Postoperative complication < 90 d, % (#) 20.8 (5) 17.9 (5) 20.8 (5) 0.95
Clavien-Dindo scoreb 1.8 ± 0.45 2.0 ± 0 2.2 ± 0.45 F1 vs F2: 1
F2 vs F3: 1
F3 vs F1: 0.33
Urinary tract infection < 90 d, % (#) 12.5 (3) 7.1 (2) 8.3 (2) 0.79
Wound infection < 90 d, % (#) 4.2 (1) 7.1 (1) 8.3 (2) 0.83
Readmission < 30 d, % (#) 0 0 0 --

a. Comparisons performed with χ2/Fisher’s exact tests for categorical variables and analysis of variance for continuous variables.

b. Clavien-Dindo score, as defined by Clavien et al23, calculated and compared for participants with postoperative complications only.

DISCUSSION

Principal Findings

We describe the first structured training pathway for robotic-assisted gynecologic surgery that integrates simulation, observation, and graduated task performance based on step-specific benchmark operative times. Such pathways are vital for robotic surgery, in which the single-surgeon design disrupts traditional surgical teaching approaches. Using our structured RASC training pathway, fellow participation did not increase operative times for total procedure, sacrocolpopexy, or any RASC step compared with attending RASC (including learning curve cases). There were no differences in complication or readmission rates for fellow involvement.

Clinical Implications

Within our pathway, operative times were similar for RASC with and without fellows, illustrating the ability of a structured training pathway to maintain acceptable operative times for RASC by scaling trainee participation within pre-set benchmark operative times. Total procedure times were longest for F2, but times for sacrocolpopexy and all operative steps besides port placement were similar across fellow years. The longer total procedure time for F2 may be explained in part by the trend toward higher hysterectomy rate for F2 or by operative steps that were not directly measured, such as lysis of adhesions. Another likely contributor is the graduated task performance within our teaching pathway, that is, F2 fellows had achieved the skills to perform most of the procedure, while still improving efficiency. F2 port placement times were also longest, likely again owing to this skill-efficiency effect. Regardless, the difference in port placement times for F2 versus F3 – 4.2 minutes – is likely not clinically relevant.

F1 fellows, as expected, required the most attending intervention, because they are often relatively naïve to both robotics and sacrocolpopexy. In our experience within this structured training pathway, F1 fellows performed up to 60% of RASC, increasing to 80% to 100% by F2 and 100% during the F3 year.

Results

Our RASC operative times are consistent with those of prior studies, which range from 124.5 to 359.7 minutes,8,24-27 with a systematic review reporting pooled total operating time of 230.5 ± 19.6 minutes.27 Carter-Brooks et al26 reported on 208 RASC procedures and demonstrated longer operative times for fellows compared with attendings (155.6 vs 124.5 minutes, p < 0.001). The shorter operative times compared with our study may relate to lower concomitant procedure rates (sling in 17.3% and perineorrhaphy in 3.4%) or differences in RASC technique. As described by Carter-Brooks et al,26 F1 performed 30% to 40% of RASC, whereas F2 performed 50% to 70%, and F3 performed 90% to 100%, suggesting lower F1 and F2 participation compared with our protocol.

In another retrospective study, Crane et al29 described a training protocol for RASC in which postgraduate year (PGY)-5 (analogous to F1) performed vaginal mesh attachment, PGY-6 (F2) also performed vaginal dissection, and PGY-7 (F3) performed all RASC steps. This protocol again suggests less fellow participation but produced similar RASC times to our study, with a trend toward longer trainee times (200 vs 182 minutes, p = 0.08). Although the Crane et al29 study assigned progressive-step complexity by trainee year, it did not incorporate simulation or step-specific benchmarks. We believe these novel elements of our training pathway provide important safety and quality checks. We found no differences in complication or readmission rates based on fellow involvement, consistent with prior publications.26,28

In our study, participants undergoing RASC without fellows had a trend toward more previous incontinence surgery, likely explaining the higher sling rate for fellow RASC. V-Loc was used more often for vaginal mesh attachment in fellow RASC; however, multiple interrupted sutures were still placed. There was no difference in vaginal mesh attachment times without and with V-Loc for attendings (33.3 ± 20.1 vs 35.6 ± 31.9 minutes, p = 0.71) or fellows (35.8 ± 17.8 vs 35.9 ± 15.4 minutes, p = 0.98). Therefore, we do not believe differences in V-Loc use biased study results. Three sacral sutures (rather than 2) were placed more often in fellow cases; this did not significantly impact operative time.

Research Implications

Given implementation of structured training from the outset of robotic sacrocolpopexy at our institution, we cannot directly compare times before and after implementation. However, a study published in 2011 at the other training site in our joint FPMRS fellowship program reported an average total procedure RASC time of 281 ± 58 minutes.25 This study was conducted within the same teaching fellowship using the same standardized RASC technique, and therefore provides an indirect prestructured training baseline, with which our operative times compare favorably. Directions for future research include: 1) comparison of fellow versus attending times based on proportion/steps of RASC performed, 2) randomized investigation of structured training, 3) impact of structured training on fellows’ future performance, and 4) adaptation of our training pathway to other procedures and/or specialties.

Strengths and Limitations

Strengths of our study include prospective design, implementation of novel RASC training program, and step-specific measurement of operative times. This study is unique in that we were able to compare attendings experienced in laparoscopic sacrocolpopexy but new to robotic surgery with fellows who had limited experience with either the procedure or the robotic modality.

Limitations include potential measurement or observer bias, because operative times were recorded intraoperatively by surgeons. Two attendings were typically present for fellow RASC, which may not be replicable in all teaching settings. Although our managed care model generally leads to high rates of patient retention, complications managed at outside facilities would not have been captured. Finally, we did not track which RASC steps were performed by fellows or how often attendings needed to complete a step. Despite the above limitations, our study is the first to analyze the impact of a comprehensive, structured fellow training program on operative times in RASC and may provide a useful template for future surgical training programs.

CONCLUSION

In conclusion, our structured robotic surgical training program achieves similar total and step-specific operative times for RASC with and without fellows. Perioperative morbidity was low and similar for fellow and attending RASC. This novel approach to surgical education warrants further study to determine its potential contribution to quality improvement and patient safety in the teaching environment.

Disclosure Statement

No acknowledged individuals have financial conflicts of interest or sources of funding for this project.

Acknowledgments

The authors would like to thank all of the patients who agreed to participate in this study, as well as Gisselle Zazueta-Damian and Linda MacKinnon for their invaluable research support. Gisselle Zazueta-Damian and Linda MacKinnon are both affiliated with the Department of Obstetrics and Gynecology, Division of Female Pelvic Medicine and Reconstructive Surgery, Kaiser Permanente San Diego, San Diego, CA.

This is a substudy of a prospective clinical trial registered at clinicaltrials.gov (NCT01535833).

Author Affiliations

1Department of Obstetrics and Gynecology, Division of Female Pelvic Medicine and Reconstructive Surgery, Southern California Permanente Medical Group, San Diego, CA

2Department of Obstetrics and Gynecology, Division of Female Pelvic Medicine and Reconstructive Surgery, Southern California Permanente Medical Group, Downey, CA

Corresponding Author

Tatiana Catanzarite, MD, MAS (tatiana.l.catanzarite@kp.org)

Funding

There were no funding sources for this project.

Author Contributions

Tatiana Catanzarite, MD, MAS, participated in study design, acquisition and analysis of data, and manuscript preparation. Jasmine Tan-Kim, MD, MAS, participated in study design, data collection, data interpretation, and manuscript review/preparation. John N. Nguyen, MD, participated in study design, data collection, and critical review of manuscript/manuscript preparation. Sharon Jakus-Waldman, MD, participated in study design, data collection, and critical review of manuscript/manuscript preparation. Shawn A. Menefee, MD, participated in study design, data collection, and critical review of manuscript/manuscript preparation.

Abbreviations

F1, FPMRS fellow year 1; F2, FPMRS fellow year 2; F3, FPMRS fellow year 3; FPMRS, Female Pelvic Medicine and Reconstructive Surgery; PGY, postgraduate year; RASC, robotic-assisted sacrocolpopexy

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Keywords: operative time, patient safety, robotic sacrocolpopexy, surgical training, urogynecology

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