10-yr Outcomes of Senior Clinical Fellowship in Robot-assisted Radical Cystectomy (RARC) with focus on Intracorporeal Ileal Conduit Urinary Diversion: Aggregated Learning Curve Assessment and Achievement of the EAU-Robotic Urology Section (ERUS) RARC Curriculum.

OBJECTIVE

(1) To examine 10-yr outcomes of Robot-assisted Radical Cystectomy (RARC) with Intracorporeal Ileal Conduit (ICIC) performed by international clinical fellows within a 1-yr RCS-Eng Urothelial Senior Fellowship Programme. (2) To explore fellows' learning curve (LC) trajectories and perceived European Association of Urology Robotic Urology Section (ERUS) RARC/ICIC curriculum competency achievement.

METHODS

RARC/ICIC with curative intent for bladder cancer performed by supervised fellows (2015-2025) were reviewed. Perioperative outcomes and Kaplan-Meier survival trajectories served as surrogates of training competency and safety. Cumulative sum (CUSUM) model by operative time (OT) was applied for RARC/ICIC LC. Time to perceived proficiency across the 12 ERUS RARC/ICIC clinical modules was explored.

RESULTS

A total of 423 procedures (median follow-up 39 mo, interquartile range 16-70) were included. Proficiency by CUSUM was identified at 30th case, with significant reduction in total OT thereafter (350 vs 300 min, p = 0.017). Outcomes within learning and proficiency phases were comparable, including postoperative complications (36.6% vs 46.0%, p = 0.07), readmissions (16.9% vs 18.7%, p = 0.68), and cancer-specific survival (p = 0.97). ERUS curriculum acquisition was progressive: early modules in 0-1 mo by 88.9% of fellows and advanced modules in 4-6 mo by 100%. Skin-to-skin RARC/ICIC was achieved within ≤3, 4-6, and >6 mo in 11.1%, 33.3% and 55.6% of fellows, respectively. Previous robotic exposure was the only predictor for shorter time to independence (odds ratio, 2.34; 95% confidence interval 1.17-13.29). Post-fellowship, 88.9% of fellows continued independent RARC/ICIC practice.

CONCLUSIONS

Structured Senior Robotic Fellowship training achieves safe and efficient acquisition of RARC/ICIC skills. The observed LC corroborates the educational value of the ERUS modular curriculum in the setting of a tertiary referral center.