Alexander Beulens

161 Linking surgical skills to postoperative outcomes: a Delphi study on the robot assisted radical prostatectomy Introduction In the Netherlands, approximately 2500 radical prostatectomies are performed annually of which 90% are performed using the surgical robot, i.e. robot-assisted radical prostatectomy (RARP). The RARP is a complex but highly standardized operation to cure local prostate cancer. However, RARP is hampered by serious side-effects1–3 such as urinary incontinence, which occurs in 4 to 26% of the patients4–6, and erectile dysfunction, which occurs in 14 to 90% of the patients.7,8 Previous research has shown that greater surgical experience is associated with better postoperative outcomes.9-11 Therefore, the Dutch Society of Urology (NVU) increased the minimally required number of annual RARP per hospital from 50 to 100 procedures to improve functional results and reduce complications. However, at the moment there is no minimum annual number of procedures per surgeon. Various authors suggested that systematic evaluation of skills, both technical (surgical) and non-technical (communication and teamwork) may be more effective in improving the surgeons’ skills than a quota alone.12,13 Thorough analysis of surgical videos can possibly elucidate which steps or facets of surgery may be related to disadvantageous results such as postoperative complications (i.e. bleeding and leakage of the vesico-urethral anastomosis) and adverse functional outcomes (i.e. erectile dysfunction, incontinence).12,14 To standardize video analysis, a detailed description of all the separate surgical steps is needed. In the past, different assessment instruments containing individual steps of the RARP have been defined15–17, but these methods are mostly intended for providing feedback during training of new robotic surgeons or to evaluate the skills of more experienced robotic surgeons by means of video analysis. So far, no specific method has been developed to investigate how a surgeon’s skills and surgical events as assessed on video are related to adverse postoperative outcomes of RARP. The present Delphi study is designed to evaluate whether experts in the field of RARP can identify the surgical and non-surgical factors in RARP that are potentially associated with negative aspects of postoperative outcomes. The following key questions were to be answered: which steps of the RARP and which peri-operative events (i.e. bleeding, usage of coagulation, usage of haemostatic clips and suturing) are most likely associated with postoperative complications (i.e. bleeding and leakage of the vesicourethral anastomosis) and adverse functional outcomes (i.e. erectile dysfunction, incontinence)? How can these steps of the RARP and these peri-operative events be incorporated in an RARP assessment instrument?