Only a small number of studies were identified, most of them with methodological issues affecting their validity. Definitions of high and low volumes differ across studies and make comparisons between studies and indications difficult.
The limited evidence is strongest for urological procedures and shows positive associations between higher volume centres and better outcomes.
Gynaecological RAS – no systematic reviews identified; recent observational studies primarily considered minimally invasive surgery in general and did not separate out results for RAS.
Colorectal RAS – no systematic reviews identified; several recent observational studies primarily considered minimally invasive surgery in general and did not separate out results for RAS. One retrospective observational study (based upon 957 procedures) reported improvements in operative times, conversion rates and length of stay for high versus low volume surgeons.
Urological RAS (radical prostatectomy) – one systematic review that primarily reported collated outcomes for all type of surgery, concluded that higher volume surgical centres have better outcomes and this relationship is still seen when considering RAS alone. Two large retrospective observational studies from the United States reported improvements in a number of outcomes with higher volume hospitals, but used different volume definitions complicating comparisons. Two cost analyses (United States and Australia) showed reduced costs at higher volume centres.
Urological RAS (radical cystectomy) – one systematic review was identified which included 49 studies but considered all surgical approaches. Only one included primary study reported RAS outcomes (based upon data gathered back to 2011) and considered a comparison of the first one hundred with the second hundred patients. Other than a shorter operative time for the latter group, no differences in outcomes were observed.
Urological RAS (partial nephrectomy) – two retrospective observational studies reported improvements in various outcomes with increasing hospital volume. One of the studies also considered surgical volume and again showed improvements in outcomes with increasing volume. A multivariate analysis however found that when adjusting for other variables hospital volume but not surgeon volume was associated with achieving the Trifecta outcome.
Learning curves – one recent systematic review was identified which included 49 studies. The review authors present the number of procedures necessary to ‘overcome the learning curve’ for various clinical and oncology specific outcomes. They note the generally poor methodological quality of much of the evidence and the need to interpret the results with caution.
What were we asked to look at?
We were asked to provide an evidence summary on the impact of the number of robotic-assisted procedures (gynaecological, colorectal, urological) per treatment centre/surgeon on the outcomes achieved, and any related evidence on the learning curves for these procedures.
Why is this important?
As robotic-assisted surgery is used more frequently and across a growing number of
indications in NHSScotland, it is essential that surgeons and hospitals undertake sufficient
numbers of procedures to ensure optimal effectiveness, safety and cost effectiveness.
The National Planning Robotic Review Group