An Eight-Month Preliminary Analysis of Robotic-Assisted Radical Prostatectomy (RARP) Proficiency Metrics in a Robotic Fellowship-Naïve Surgeon During a Pelvic Uro-Oncology Fellowship Training

Abstract

Structured, competency-based fellowships are essential for training in complex robotic surgery. This study analyses the initial learning curve of a robotic-fellowship-naïve surgical fellow performing robotic-assisted radical prostatectomy (RARP) within a high-volume, metrics-driven pelvic oncology fellowship, culminating in the milestone achievement of complete skin-to-skin independent performance.

A prospective database of 68 consecutive RARP procedures (July 2025 – February 2026) was analysed. Primary endpoints were fellow participation as console surgeon, console time, and binary completion of 13 modular procedural phases. The phases were conceptually aligned with published modular training frameworks for RARP, comprising 12 phases adapted from established curricula plus a 13 ^th phase representing complete skin-to-skin case performance. Secondary endpoints included clinical safety indicators (transfusion rate, length of stay, complications) and biochemical outcomes (postoperative prostate-specific antigen, PSA). Statistical analysis employed the Mann–Kendall test for trend analysis and Fisher’s exact test for association testing.

The fellow participated in all 68 RARPs, acting as console surgeon under supervision in 48 cases (70.6%). Median fellow-specific console time was 32 minutes (IQR 20–45). A strong positive temporal trend was observed in the number of phases performed per case (Mann–Kendall τ = 0.61, p < 0.01). All 12 procedural phases were successfully completed by the fellow, with apical dissection first completed in case 57. The 13 ^th phase — complete skin-to-skin RARP — was achieved in cases 67 and 68, with console times of 190 and 160 minutes, respectively, representing 100% of total operative console time. No patients required perioperative blood transfusion (0/68) or surgical drainage. One patient (Case 67, 1.5%) experienced a Clavien–Dindo grade II complication requiring postoperative antibiotics. A transurethral catheter was used in 67 cases, with one suprapubic catheter as part of an enhanced recovery protocol. 95.6% (65/68) of patients were discharged on the first postoperative day. The fellow participated in 17 RARP and 7 RARC extended pelvic lymphadenectomies (ePLND). Postoperative PSA data were available for 51 cases. Of these, 41 (80.4%) achieved an undetectable PSA (< 0.1 ng/ml), while 10 cases (19.6%) had detectable PSA ranging from 0.1 to 3.5 ng/ml. Final histo-pathology was available for 50 cases, revealing a positive surgical margin (PSM) rate of 40.0% (20/50). Among patients with both PSA and margin data available (n = 49), 39 (79.6%) had undetectable PSA, with 13 (33.3%) of these having a reported PSM. The Fisher’s exact test confirmed no significant association between PSA undetectability and margin status (p = 0.20).