Comparison of Surgical Outcomes of Robot-assisted Radical Prostatectomy between Residents under our Training Curriculum and Experienced Surgeons: A Propensity Score-matched Analysis

Comparison of Surgical Outcomes of Robot-assisted Radical Prostatectomy between Residents under our Training Curriculum and Experienced Surgeons: A Propensity Score-matched Analysis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Comparison of Surgical Outcomes of Robot-assisted Radical Prostatectomy between Residents under our Training Curriculum and Experienced Surgeons: A Propensity Score-matched Analysis Sunao Nohara, Yu Ozawa, Keisuke Aoki, Shin Koike, Kei Ushijima, and 6 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7066257/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 11 Apr, 2026 Read the published version in International Journal of Clinical Oncology → Version 1 posted 5 You are reading this latest preprint version Abstract Background We developed a robot-assisted training curriculum for urology residents with limited experience in open and laparoscopic surgeries. In this retrospective single-center study, we aimed to evaluate our curriculum by comparing surgical outcomes of robot-assisted radical prostatectomy performed by residents enrolled in the curriculum with those of procedures performed by experienced surgeons. Methods Fifty-three patients whose robot-assisted radical prostatectomy was performed by urology residents were propensity score-matched using clinicopathological characteristics to patients whose robot-assisted radical prostatectomy was performed by experienced surgeons. Surgical and pathological outcomes were compared between groups, including estimated blood loss, operative time, perioperative complication rates, positive surgical margins, and immediate urinary continence. Residents were initially trained in robot-assisted surgery. Our training program included video lectures and dry-laboratory exercises with three-dimensional pelvic models, origami training, and vesicourethral anastomosis simulation. Results Estimated blood loss and complication rates were comparable between groups. Bladder takedown and seminal vesicle dissection significantly prolonged the operative time in the resident group, which was 1.16 times longer (median 249 vs. 213 min; p < 0.001). Notably, vesicourethral anastomosis time was the only procedure with comparable time between groups (17 vs. 14 min; p = 0.082). There were no significant differences in perioperative complication rates, positive surgical margin rates, or immediate urinary continence. Conclusions Trained residents performed robot-assisted radical prostatectomy safely with acceptable surgical outcomes, despite longer operative times. Simulation-based training enables residents to perform procedures within a timeframe comparable to that of experienced surgeons; therefore, well-designed surgical models are needed for training purposes. Education Propensity Score Prostate Cancer Robotic Surgical Procedures Figures Figure 1 Figure 2 1. Introduction Japanese urology residents begin performing robotic surgery as console surgeons under the guidance of proctored doctors after acquiring experience in more than 20 cases as bedside surgeons, as required by the Japanese Society of Endourology and Robotics (JSER) [ 1 ]. They primarily perform robot-assisted radical prostatectomy (RARP), which is the most common robot-assisted surgery in urologic oncology, because prostate cancer is the most prevalent cancer among Japanese men [ 2 ], and RARP is the current standardized surgical modality for localized prostate cancer. Since 2012, when the Japanese national insurance began covering RARP [ 3 ], open and laparoscopic radical prostatectomies have been largely replaced by RARP. Urology residents often begin performing robot-assisted surgery for urological cancer without sufficient experience in open or laparoscopic surgery. Therefore, an optimized training curriculum is needed to ensure that these residents can perform robot-assisted surgery safely and effectively. Generally, robotic surgeons are required to develop skills related to indirect instrument and camera coordination, known as hand–eye coordination and workspace correspondence [ 4 ]. Surgeons must develop proficiency in controlling robotic instruments and depth perception based solely on visual cues, despite the lack of haptic feedback. Surgeons must also develop the ability to mentally map the relationships between the camera view, instruments, and target within the surgical workspace. Especially in RARP, precise manipulation in a narrow workspace is essential because the prostate gland is located deep in the pelvis [ 5 ]. Many training curricula have been developed in recent years, and the evaluations of these programs vary [ 6 – 9 ]. No definitive assessment tool exists in robotics, making it challenging to establish concurrent validity [ 7 ]. For example, the European Association of Urology introduced a robotic training curriculum that includes theoretical training, live case observation, bedside assistance, laboratory exercises (both dry and wet laboratory exercises), and modular console training [ 6 ]. To objectively evaluate training, laboratory exercises are assessed using the Global Evaluative Assessment of Robotic Skills, and full-length videos of RARP performed by trainees are evaluated and scored by experts [ 10 ]. Few studies have compared surgical outcomes to assess the efficacy of the training curriculum. Formal training in RARP has led to improved surgical and pathological outcomes compared to those achieved with laparoscopic prostatectomy training [ 11 ]. However, some concerns remain. Detailed training content has not been accounted for, and current training is insufficient to ensure patient safety [ 12 ]. A standardized training curriculum for robotic surgery has yet to be established [ 13 ]. In this context, we developed our robotic training curriculum, focusing on residents without experience in open and laparoscopic surgery. Our curriculum was implemented until the residents became independent primary surgeons. In this study, we evaluated the usefulness of our training curriculum by comparing the outcomes of RARP performed by residents with the outcomes of those performed by non-resident surgeons. Additionally, we analyzed the impact of the curriculum on surgical outcomes across various procedural components. 2. Patients and Methods 2.1 Patient cohort This was a single-institution retrospective study. Informed consent was obtained from all participants using the opt-out method (Approval No: 240625B). A total of 278 patients with localized prostate cancer underwent RARP at Itabashi Chuo Medical Center between April 2021 and April 2023. Salvage RARP was not included. The patients’ medical records were reviewed, and 50 patients who underwent RARP performed by a surgeon with extensive laparoscopic surgery experience (certified by JSER as a urological laparoscopic surgeon) were excluded. The remaining 228 patients were included. All patients had a pathological diagnosis of prostate cancer before surgery and underwent computed tomography, magnetic resonance imaging, and bone scintigraphy for staging. Eight surgeons performed RARP using the Da Vinci Xi system (Intuitive Surgical, Sunnyvale, CA, USA) with the same techniques and procedures. Three surgeons were not resident and certified as RARP proctors by the JSER (with more than 40 cases of primary surgical experience), while five surgeons were urological residents: two with limited laparoscopic surgery experience (approximately 10 cases of laparoscopic radical nephrectomy) and three with no laparoscopic surgery experience. We defined RARPs performed by non-resident surgeons as non-resident RARPs (nrRARPs) and those performed by residents as resident RARPs (rRARPs). All surgeries performed by residents were conducted under the supervision of non-resident surgeons. The non-resident surgeons partially took over the key parts of the operation if deemed necessary during surgery to ensure patient safety or to avoid compromising oncological and functional outcomes. 2.2 Propensity score matching To mitigate confounding factors, 53 patients who underwent rRARP were matched with 53 patients who underwent nrRARP in a 1:1 ratio from our cohort of 175 patients without replacement. This matching was based on propensity score matching including age, body mass index (BMI), initial prostate-specific antigen (iPSA) level, and International Society of Urological Pathology (ISUP) biopsy category. We adopted the 2014 ISUP grading system for Gleason grade evaluation [ 14 ]. We compared surgical and pathological outcomes between the two groups, including operative time, console time, estimated blood loss, perioperative complications during hospitalization, positive surgical margin rate, and immediate urinary continence. Perioperative outcomes have been reported according to the Clavien–Dindo grade [ 15 ]. Perioperative complications with Clavien–Dindo grade ≤ 2 were minor complications, while those with Clavien–Dindo grade ≥ 3 were severe complications. We removed the urinary catheter on postoperative days 6 or 7 after checking for no leakage from the vesicourethral anastomosis site on cystography. After catheter removal, patients kept a voiding diary, recording urinary parameters such as frequency of urination and the amount of urinary leakage. Immediate urinary continence was defined as the ratio of the 24-h urine loss volume to the total urine volume per day immediately after urinary catheter removal (the sixth or seventh postoperative day). Thus, zero immediate urinary continence referred to full continence without stress urinary incontinence after catheter removal, commonly described as “no urine leakage”. We divided RARP procedure into five parts: (1) bladder takedown to the division of endopelvic fascia, (2) bladder neck transection (anterior approach), (3) seminal vesicle dissection to the division of the urethra, (4) posterior reconstruction to anterior reconstruction, and (5) vesicourethral anastomosis. Perioperative and postoperative variables were analyzed to determine performance differences between the two groups using Fisher’s exact test and the Mann–Whitney U test. All statistical analyses were performed using R version 4.0.0 (R Foundation for Statistical Computing, Vienna, Austria) and EZR (Saitama Medical Center, Jichi Medical University, Saitama, Japan), graphical user interfaces for R. Statistical significance for all analyses was defined as p < 0.05. 2.3 Surgical techniques All RARPs were performed using the same procedure and technique, specifically conventional RARP with a transperitoneal approach, as previously described [ 16 ]. Our procedures included patient positioning, port placement, bladder takedown, division of the endopelvic fascia, bladder neck transection (anterior approach), seminal vesicle dissection, posterior dissection of the prostate, lateral to apical dissection, dorsal vascular complex cutting and ligation, division of the urethra, lymph node dissection (in high-risk cases), posterior reconstruction, vesicourethral anastomosis, and anterior reconstruction. Unilateral antegrade nerve-sparing procedures were performed in nerve-sparing cases; therefore, bilateral nerve-sparing procedures were not performed. Lymph node dissection was performed for high-risk patients based on their life expectancy and oncological profiles. Non-resident surgeons performed all lymph node dissections in rRARP. High-risk patients received neoadjuvant hormonal therapy for 6 months using luteinizing hormone-releasing hormone agonists or antagonists and nonsteroidal antiandrogens (bicalutamide). 2.4. Training curriculum All residents received the same training. Our training curriculum included dry-laboratory and theoretical training. Dry-laboratory training used a three-dimensional (3-D) pelvic model (Fasotec, Chiba, Japan) to develop skills for working in a narrow space, including origami training and vesicourethral anastomosis (Fig. 1 ). Entire dry-laboratory training was conducted in a 30º Trendelenburg position, consistent with the conditions for RARP. Table 1 lists the training methods we used and the equipment involved. Residents had to complete over 40 h of dry-laboratory training and participate in more than 20 RARP cases as bedside surgeons before performing RARP as a console surgeon. However, since we believe that 40 h of dry-laboratory training is insufficient, residents continued their training even after they became console surgeons. Table 1 Our dry-laboratory training list Dry-laboratory training Content Skills to improve Instruments used Materials used Origami training Create a crane with origami paper Delicate touch without damaging tissues, hand–eye coordination Large needle driver x2 2.5 cm square origami paper Vesicourethral anastomosis Perform vesicourethral anastomosis using a model Learn the steps, needle handling at various angles, hand–eye coordination Large needle driver x2 Urethrovesical Model (Fasotec, Chiba, Japan), 3–0 Monocryl sutures (14 cm), tied at both ends 2.4.1 Origami training A 2.5-cm square paper was used to fold an origami crane, which requires gentle and precise manipulation to avoid tearing the paper. This practice can enhance visual–tactile sensitivity and improve proficiency in gentle forceps manipulation. Since the Da Vinci system, except for the Da Vinci Ⅴ, lacks a sense of touch, beginner surgeons may unintentionally damage organs with forceps, leading to major complications. Developing visual–tactile sensitivity helps prevent traction injuries to key muscles, such as the puboperineal muscles and urethral sphincter, as well as to nerves, which is crucial for achieving optimal functional outcomes [ 17 , 18 ]. 2.4.2 Vesicourethral anastomosis Vesicourethral anastomosis training used the Urethrovesical Model (Fasotec, Chiba, Japan) to simulate practical surgical conditions. Both training sessions enhanced hand–eye coordination, bilateral coordinated movement, and suturing skills. We performed the Van Velthoven single-knot running suture with bidirectional 3 − 0 monofilament. The method for holding the needle and placing sutures is standardized and must be followed in practice. Therefore, every surgeon in our hospital performs vesicourethral anastomosis in the same manner. The goal is to complete the anastomosis within 10 min. 2.4.3 Video lecture Theoretical training was conducted via online meetings. A senior doctor taught surgical anatomy and procedures to multiple residents while showing surgical videos. After each case, the senior doctor reviewed the residents’ surgeries. In addition to discussing the residents’ thought processes during each surgical procedure, the senior doctor always reviewed each resident’s case and shared suggestions for improvement. The meeting videos were stored with patient personal details hidden, allowing residents to access and review them repeatedly. 3. Results 3.1 Baseline characteristics after propensity score matching After 1:1 propensity score matching, the two groups exhibited similar preoperative characteristics, including age, BMI, iPSA, biopsy ISUP category, estimated prostate volume, PSA density, clinical tumor stage, and National Comprehensive Cancer Network risk group (Table 2 ). Table 2 Comparison of preoperative characteristics between non-resident and resident performed Robot-assisted radical prostatectomy (RARP) after 1:1 propensity score matching Measured parameter Non-resident RARP Resident RARP p value Number of patients 53 53 Age at surgery (year), median (IQR) 70.0 (65.0, 74.0) 69.0 (65.0, 73.0) 0.567 Body Mass Index (kg/m 2 ), median (IQR) 24.2 (22.9, 25.4) 24.1 (22.1, 25.4) 0.445 Initial PSA (ng/mL), median (IQR) 6.55 (5.10, 9.10) 6.16 (4.90, 11.2) 0.698 Biopsy International Society of Urological Pathology Grade, n (%) 0.776 Grade 1 5 (9.4) 9 (17.0) 0.776 Grade 2 10 (18.9) 12 (22.6) Grade 3 12 (22.6) 10 (18.9) Grade 4 17 (32.1) 14 (26.4) Grade 5 9 (17.0) 8 (15.1) Estimate prostate volume (mL) a , median (IQR) 40.0 (35.0, 55.0) 40.0 (30.0, 45.0) 0.093 PSA density, median (IQR) 0.16 (0.11, 0.25) 0.16 (0.12, 0.30) 0.431 cT stage, n (%) 0.169 cT1 8 (15.1) 10 (18.9) cT2 39 (73.6) 42 (79.2) cT3 6 (11.3) 1 (1.9) cT4 0 (0.00) 0 (0.00) National Comprehensive Cancer Network risk group, n (%) Low 5 (9.43) 6 (11.3) 0.405 Intermediate 19 (35.8) 25 (47.2) High 29 (54.7) 22 (41.5) Data are presented as median values with IQRs or number of patients with percentages. Abbreviations: cT clinical Tumor, IQR inter quartile range, PSA prostate-specific antigen, RARP Robot-assisted radical prostatectomy a Estimated prostate volume was calculated by staging CT before neoadjuvant hormone therapy. Table 3 shows the perioperative characteristics and surgical outcomes between the non-resident groups and resident groups who performed RARP after 1:1 propensity score matching. Regarding perioperative characteristics, there were no significant differences in the rates of neoadjuvant hormone therapy and pelvic lymph node dissection (PLND) between the two groups. Table 3 Comparison of perioperative characteristics and surgical outcomes between non-resident and resident performed robot-assisted radical prostatectomy (RARP) after 1:1 propensity score matching Measured parameter Non-resident RARP Resident RARP p value Number of patients 53 53 Neoadjuvant hormone therapy, n (%) 24 (45.3) 25 (47.2) 1.00 Past history of TURP, n (%) 4 (7.54) 0 (0.00) 0.118 Past history of abdominal surgery, n (%) 11 (20.8) 15 (28.3) 0.499 Nerve-sparing procedure, n (%) 6 (11.3) 4 (7.54) 0.741 PLND, n (%) 13 (24.5) 16 (30.2) 0.663 Extended PLND, n (%) 7 (13.2) 8 (15.1) 1.00 Partial PLND, n (%) 6 (11.3) 8 (15.1) 0.775 Operative time (min), median (IQR) 213 (183, 238) 249 (225, 283) < 0.001 Console time (min), median (IQR) 170 (143, 194) 211 (185, 237) < 0.001 Console time without PLND (min), median (IQR) 160 (141, 179) 199 (182, 217) < 0.001 (1) Bladder takedown to division of endopelvic fascia 30.0 (25.0, 38.0) 45.0 (38.8, 50.3) < 0.001 (2) Bladder neck transection 15.0 (12.0, 21.0) 20.0 (16.8, 28.0) < 0.001 (3) Seminal vesicle dissection to division of the urethra 49.0 (40.0, 60.0) 66.0 (54.0, 77.0) < 0.001 (4) Posterior reconstruction to anterior construction 54.0 (45.0, 69.0) 63.0 (54.8, 71.3) 0.018 (5) Vesicourethral anastomosis 14.0 (11.0, 19.0) 17.0 (14.0, 22.0) 0.082 Estimated blood loss (mL), median (IQR) 200 (100, 300) 170 (100, 300) 0.683 Specimen Weight (g), median (IQR) 43.0 (32.0, 57.0) 38.0 (31.0, 49.0) 0.307 pT stage, n (%) pT2 41 (77.4) 45 (84.9) 0.326 pT3a 8 (15.1) 6 (11.3) pT3b 4 (7.5) 1 (1.9) Extraprostatic extension, n (%) 11 (20.8) 7 (13.7) 0.523 Positive surgical margins, n (%) Overall 7 (13.2) 4 (7.5) 0.526 Among pT2 2 (4.9) 3 (6.7) 1.00 Among pT3 5 (41.7) 1 (14.3) 0.333 Immediate urinary incontinence rate, n (%) 0% 23 (43.4) 23 (43.4) 1.00 < 5% 36 (67.9) 33 (62.3) 0.684 < 10% 40 (75.5) 39 (73.6) 1.00 Perioperative complication, n (%) Clavien–Dindo grade II 0 (0.00) 0 (0.00) 1.00 Clavien–Dindo grade III a 0 (0.00) 1 (1.88) 1.00 Clavien–Dindo grade IV and V 0 (0.00) 0 (0.00) 1.00 Data were presented as median values with IQRs or numbers of patients with percentages. Abbreviations: IQR inter quartile range, PLND pelvic lymph node dissection, pT pathological Tumor, RARP Robot-assisted radical prostatectomy, TURP transurethral resection of prostate a Rectal injury 3.2 Surgical and pathological outcomes The rRARP group took 36, 41, and 39 min longer in terms of total operative time (249 vs. 213 min; p < 0.001), console time (211 vs. 170 min; p < 0.001), and console time without PLND (199 vs. 160 min; p < 0.001), respectively. To investigate which parts required more time, we further divided the procedures into five parts and compared the two groups with regard to each part. The surgeons in the rRARP group took 15, 5, 17, 9, and 3 min longer for the procedure of bladder takedown to the division of endopelvic fascia (45 vs. 30 min; p < 0.001), that of bladder neck transection (anterior approach) (20 vs. 15 min; p < 0.001), that of seminal vesicle dissection to the division of the urethra (66 vs. 49 min; p < 0.001), that of posterior reconstruction to anterior reconstruction (63 vs. 54 min; p = 0.018), and that of vesicourethral anastomosis (17 vs. 14 min; p = 0.082), respectively (Fig. 2 A, B, C, and D). No significant difference was observed in the procedure of vesicourethral anastomosis (Fig. 2 E). Regarding pathological outcomes, no significant difference existed in the pathological T stage, extraprostatic extension, or positive margins across all T stages, including the pathological T2 and T3 groups. Immediate urinary incontinence was comparable between the two groups. The rates of Clavien–Dindo classification grades II and III were comparable; no severe perioperative complications (Clavien–Dindo classification grades IV or V) were noted during hospitalization. One case of a grade III complication in the rRARP group involved a rectal injury, which occurred when the suction tube, handled by the bedside surgeon, inadvertently punctured the rectum during posterior dissection. It required two-layer suturing to close the small hole. The postoperative course was uneventful and similar to that of the other patients. 4. Discussion Previous studies evaluating different training methods in urology have primarily focused on skill acquisition rather than on directly demonstrating improved outcomes and reduced complications [ 6 – 9 , 19 ]. In contrast, our training program included both dry-laboratory and theoretical training and has proven effective in preparing residents to perform RARP. Additionally, we focused on the effectiveness of training by comparing surgical outcomes. Various training methods aimed at developing both technical and non-technical skills necessary for performing robotic surgery safely and effectively have been reported. The emphasis is placed on a structured, comprehensive approach that combines theoretical knowledge, simulated practice, and supervised clinical experience before allowing independent practice [ 4 – 7 ]. Our training curriculum incorporated these components as well. Herein, we evaluated the usefulness of our training curriculum by comparing outcomes of RARP performed by residents (rRARP group) with those of that performed by non-resident surgeons (nrRARP group). The surgeons in the rRARP group required significantly longer operative and console times than those in the nrRARP group, likely owing to their need to develop proficiency in robotic surgical techniques. This was particularly evident in the procedures of bladder takedown to the division of the endopelvic fascia, bladder neck transection, and seminal vesicle dissection to urethra division. These procedures exhibited significant variability from case to case. We needed to tailor surgical techniques based on the degree of periprostatic adhesion, prostate shape, and oncological profile, which required extensive surgical experience. However, this experience, traditionally gained through open or laparoscopic surgery, was lacking among residents, who needed some time to adapt to the variability among cases. By contrast, there were no significant differences in the vesicourethral anastomosis procedure. This result is likely to be attributed to a well-designed simulation model. The high quality and reproducibility of the anastomosis model allow residents to practice repeatedly. Because the residents followed predetermined needle handling and suturing techniques using uniform sutures and needles that matched real procedures, they could perform anastomosis during surgery as practiced in dry-laboratory training. Additionally, anastomosis shows little individual variation across cases. The variability in anastomosis cases is less significant than that in periprostatic dissection, making it more conducive to consistent practice. In terms of postoperative outcomes, we found no significant differences in pathological T stage, extraprostatic extension, positive surgical margins, the incidence of perioperative complications classified as Clavien–Dindo grades II and III, or immediate urinary continence between the two groups. These data indicate that, despite longer operative times (which did not exceed 4 h), the residents safely achieved similar oncological and urinary continence outcomes as the non-resident surgeons. This study had a few limitations. First, we assigned only non-challenging cases to residents, limiting them to perform procedures on patients with a prostate volume of 40 mL or less, those without significant median lobe enlargement, and those without nerve-sparing procedures. Conversely, non-resident surgeons performed procedures on patients with high BMI, history of abdominal surgery or TURP, large prostate volumes, median lobe enlargement, or nerve-sparing procedure, which required more advanced skills [ 20 ]. Our patient selection contributed to the feasible outcomes of rRARP and enhanced the efficacy of residents’ training. Second, difficult situations, even in non-challenging cases, were managed by the attending non-resident surgeon. Certain parts of rRAPR were taken over by non-resident surgeons as needed. Although the decision for non-resident surgeons to take over surgical aspects of the rRARP introduced intervention bias, non-resident surgeons’ supervision and guidance played a role in ensuring the safety and comparable outcomes of rRARP. Third, our findings were limited by the study’s retrospective nature and small sample size. Despite these limitations, our data underscored the value of structured resident training programs, particularly repeated training with a more practical model, in improving surgical proficiency. Our study findings highlighted the importance of well-designed surgical training models. However, the current model remains inadequate owing to its high cost, limited time, and restricted availability of training facilities. While the anastomosis model proved to be reproducible and useful for practice, most other models are not practical at a functional level. Apart from the anastomosis model, we were unable to use other well-designed models, making it challenging to simulate each RARP procedure owing to the complexity of clinical anatomy in bladder takedown, bladder neck transection, seminal vesicle dissection, and urethral division. Nevertheless, various novel surgical models and simulators, such as virtual reality models and 3-D-printed organ models, are currently under development, offering hope that new technologies will help overcome these challenges [ 21 , 22 ]. Although we do not consider experience in open or laparoscopic surgery to be unnecessary for residents, our results suggest that such experience can be supplemented through appropriate and structured training. As it becomes increasingly difficult to ensure that every resident gains sufficient experience in open or laparoscopic procedures, we hope that our training program will contribute, even in part, to bridging that gap. In conclusion, our study demonstrates that residents can perform RARP safely with acceptable surgical outcomes compared to non-resident surgeons, despite longer operative times. The high reproducibility of the anastomosis model allowed the residents to reduce operative times through practice. The development of accessible and more practical training models is essential, particularly for robotic surgical training for residents lacking prior experience in open or laparoscopic surgeries. Declarations Acknowledgements We would like to thank Editage (http://www.editage.com) for English language editing. Conflict of interests The authors declare that they have no conflict of interest. Data availability statement The data supporting the findings of this study are available from the corresponding author upon a reasonable request. The datasets generated and/or analyzed during this study are available from the corresponding author on a reasonable request. Author contributions Sunao Nohara was the lead author involved with the conception of the work, data collection, statistical analysis, and article synthesis with substantial support from Yu Ozawa. Keisuke Aoki, Shin Koike, Kei Ushijima, Toshiaki Kayaba, Masumi Yamada, Yu Odagaki, Hideo Sakamoto, and Kunihiko Yoshioka contributed to the data collection. Choichiro Ozu and Kunihiko Yoshioka supervised the findings of the study. All authors substantially contributed to the revision of the manuscript and have approved the final version of the manuscript. Ethics approval The protocol for this research project was approved by a suitably constituted Research Ethics Committee of the institution, and it conforms to the provisions of the Declaration of Helsinki (Institutional Review Board, Approval No. 240625B.). Informed consent Informed consent was obtained from all participants using the opt-out method. 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Humana Totowa, NJ. https://doi.org/10.1007/978-1-60761-026-7 Shirk JD, Reiter R, Wallen EM et al (2022) Effect of 3-dimensional, virtual reality models for surgical planning of robotic prostatectomy on trifecta outcomes: a randomized clinical trial. J Urol 208:618–625. https://doi.org/10.1097/JU.0000000000002719 Costello DM, Huntington I, Burke G et al (2022) A review of simulation training and new 3D computer-generated synthetic organs for robotic surgery education. J Robot Surg 16:749–763. https://doi.org/10.1007/s11701-021-01302-8 Cite Share Download PDF Status: Published Journal Publication published 11 Apr, 2026 Read the published version in International Journal of Clinical Oncology → Version 1 posted Editorial decision: Major revisions 31 Jul, 2025 Reviewers agreed at journal 10 Jul, 2025 Reviewers invited by journal 10 Jul, 2025 Editor assigned by journal 09 Jul, 2025 First submitted to journal 07 Jul, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7066257","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":483354102,"identity":"9543d9c4-7ead-4454-a172-5bd8de740f2f","order_by":0,"name":"Sunao Nohara","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA6UlEQVRIiWNgGAWjYJACZhDBz8yQ+ABI8/ARrUWyneGxAUgLG9FaDM4zPpMAMQhqkW/gPfi4oOaevGQzc1rl1xw7GTYG5oePbuDRYnCAL9l4xrFiw35mtrTbstuSgQ5jMzbOwaeFgcdMmoctgXFmM0/abcltzEAtPGzS+LTIN4C0/Euw33CY/1ux5LZ6wloYDgC18LYlJG44zJDG+HHbYcJaDA7zGBvz9iUkz2xmSJZm3Hach42ZgF/k23sMH/N8S7Dt5z+Q+PHntmp7fvbmh4/xOowZmc2DLkIQMP4gRfUoGAWjYBSMGAAAnEU+URtiKa0AAAAASUVORK5CYII=","orcid":"https://orcid.org/0009-0008-2827-0527","institution":"Itabashi Chuo Medical Center: Itabashi Chuo Sogo Byoin","correspondingAuthor":true,"prefix":"","firstName":"Sunao","middleName":"","lastName":"Nohara","suffix":""},{"id":483354103,"identity":"7a5e4657-0052-44e7-a98c-d9fd05baf35d","order_by":1,"name":"Yu Ozawa","email":"","orcid":"","institution":"AdventHealth Orlando","correspondingAuthor":false,"prefix":"","firstName":"Yu","middleName":"","lastName":"Ozawa","suffix":""},{"id":483354104,"identity":"8794bda1-d74d-4513-958d-cbc1e5ae04b5","order_by":2,"name":"Keisuke Aoki","email":"","orcid":"","institution":"Itabashi Chuo Medical Center: Itabashi Chuo Sogo Byoin","correspondingAuthor":false,"prefix":"","firstName":"Keisuke","middleName":"","lastName":"Aoki","suffix":""},{"id":483354105,"identity":"50c93b83-263c-4f3f-abd7-56dcaf5476f5","order_by":3,"name":"Shin Koike","email":"","orcid":"","institution":"Itabashi Chuo Medical Center: Itabashi Chuo Sogo Byoin","correspondingAuthor":false,"prefix":"","firstName":"Shin","middleName":"","lastName":"Koike","suffix":""},{"id":483354106,"identity":"2550a899-3e70-44de-9c7f-8d2eca128b65","order_by":4,"name":"Kei Ushijima","email":"","orcid":"","institution":"Itabashi Chuo Medical Center: Itabashi Chuo Sogo Byoin","correspondingAuthor":false,"prefix":"","firstName":"Kei","middleName":"","lastName":"Ushijima","suffix":""},{"id":483354107,"identity":"16b2d009-791a-40b6-9ab8-cd57ca89b816","order_by":5,"name":"Toshiaki Kayaba","email":"","orcid":"","institution":"Itabashi Chuo Medical Center: Itabashi Chuo Sogo Byoin","correspondingAuthor":false,"prefix":"","firstName":"Toshiaki","middleName":"","lastName":"Kayaba","suffix":""},{"id":483354108,"identity":"1eeb03d4-fd5f-4fad-beb0-6c9262fcb1ee","order_by":6,"name":"Masumi Yamada","email":"","orcid":"","institution":"Itabashi Chuo Medical Center: Itabashi Chuo Sogo Byoin","correspondingAuthor":false,"prefix":"","firstName":"Masumi","middleName":"","lastName":"Yamada","suffix":""},{"id":483354109,"identity":"0dc8d3f1-3f76-40bc-b210-b20eb7a0c177","order_by":7,"name":"Yu Odagaki","email":"","orcid":"","institution":"Itabashi Chuo Medical Center: Itabashi Chuo Sogo Byoin","correspondingAuthor":false,"prefix":"","firstName":"Yu","middleName":"","lastName":"Odagaki","suffix":""},{"id":483354110,"identity":"c4c35f8e-369b-4eb5-905c-618101869cfe","order_by":8,"name":"Hideo Sakamoto","email":"","orcid":"","institution":"Itabashi Chuo Medical Center: Itabashi Chuo Sogo Byoin","correspondingAuthor":false,"prefix":"","firstName":"Hideo","middleName":"","lastName":"Sakamoto","suffix":""},{"id":483354111,"identity":"1860a1d4-36ed-4a22-8434-b25447865d51","order_by":9,"name":"Choichiro Ozu","email":"","orcid":"","institution":"Sanno Hospital: Sanno Byoin","correspondingAuthor":false,"prefix":"","firstName":"Choichiro","middleName":"","lastName":"Ozu","suffix":""},{"id":483354112,"identity":"c8e78613-e3c2-4142-b1bf-b3c4499c7fd1","order_by":10,"name":"Kunihiko Yoshioka","email":"","orcid":"","institution":"Itabashi Chuo Medical Center: Itabashi Chuo Sogo Byoin","correspondingAuthor":false,"prefix":"","firstName":"Kunihiko","middleName":"","lastName":"Yoshioka","suffix":""}],"badges":[],"createdAt":"2025-07-07 14:07:34","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7066257/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7066257/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s10147-026-03027-w","type":"published","date":"2026-04-11T15:57:30+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":86673563,"identity":"85403ff6-b5ed-4e82-87cc-a1bb67b5986c","added_by":"auto","created_at":"2025-07-14 11:48:07","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":490308,"visible":true,"origin":"","legend":"\u003cp\u003eIllustration of the dry-laboratory training\u003c/p\u003e\n\u003cp\u003eA shows the 3-D pelvic model (Fasotec, Chiba, Japan). B shows an origami crane created using a 2.5-cm square origami paper. C shows the training using a vesicourethral anastomosis model.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7066257/v1/9222d88da370ef2a0f5a4e03.png"},{"id":86672389,"identity":"1ab4762a-f261-4089-b7cb-a4dcbfc50364","added_by":"auto","created_at":"2025-07-14 11:40:07","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":110990,"visible":true,"origin":"","legend":"\u003cp\u003eBox plots of operative time comparisons between resident robot-assisted radical prostatectomy (RARP) and non-resident RARP\u003c/p\u003e\n\u003cp\u003eWe compared operative time between the resident RARP group and the non-resident RARP group. We categorized the RARP procedure into five parts and compared each time. We defined bladder takedown to division of endopelvic fascia as part A (A), bladder neck transection (anterior approach) as part B (B), seminal vesicle dissection to division of the urethra as part C (C), posterior reconstruction to anterior reconstruction as part D (D), and vesicourethral anastomosis as part E (E).\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-7066257/v1/888ea11836bc906d27e45fdd.png"},{"id":106808762,"identity":"f52fe8c5-a8aa-4462-8726-1c647477d0d3","added_by":"auto","created_at":"2026-04-13 16:01:03","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2166680,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7066257/v1/b06a27ed-6a4e-4e8d-8ea2-afa76ecc9220.pdf"}],"financialInterests":"","formattedTitle":"Comparison of Surgical Outcomes of Robot-assisted Radical Prostatectomy between Residents under our Training Curriculum and Experienced Surgeons: A Propensity Score-matched Analysis","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eJapanese urology residents begin performing robotic surgery as console surgeons under the guidance of proctored doctors after acquiring experience in more than 20 cases as bedside surgeons, as required by the Japanese Society of Endourology and Robotics (JSER) [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. They primarily perform robot-assisted radical prostatectomy (RARP), which is the most common robot-assisted surgery in urologic oncology, because prostate cancer is the most prevalent cancer among Japanese men [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e], and RARP is the current standardized surgical modality for localized prostate cancer. Since 2012, when the Japanese national insurance began covering RARP [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e], open and laparoscopic radical prostatectomies have been largely replaced by RARP. Urology residents often begin performing robot-assisted surgery for urological cancer without sufficient experience in open or laparoscopic surgery. Therefore, an optimized training curriculum is needed to ensure that these residents can perform robot-assisted surgery safely and effectively.\u003c/p\u003e\u003cp\u003eGenerally, robotic surgeons are required to develop skills related to indirect instrument and camera coordination, known as hand\u0026ndash;eye coordination and workspace correspondence [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Surgeons must develop proficiency in controlling robotic instruments and depth perception based solely on visual cues, despite the lack of haptic feedback. Surgeons must also develop the ability to mentally map the relationships between the camera view, instruments, and target within the surgical workspace. Especially in RARP, precise manipulation in a narrow workspace is essential because the prostate gland is located deep in the pelvis [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eMany training curricula have been developed in recent years, and the evaluations of these programs vary [\u003cspan additionalcitationids=\"CR7 CR8\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. No definitive assessment tool exists in robotics, making it challenging to establish concurrent validity [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. For example, the European Association of Urology introduced a robotic training curriculum that includes theoretical training, live case observation, bedside assistance, laboratory exercises (both dry and wet laboratory exercises), and modular console training [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. To objectively evaluate training, laboratory exercises are assessed using the Global Evaluative Assessment of Robotic Skills, and full-length videos of RARP performed by trainees are evaluated and scored by experts [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Few studies have compared surgical outcomes to assess the efficacy of the training curriculum. Formal training in RARP has led to improved surgical and pathological outcomes compared to those achieved with laparoscopic prostatectomy training [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. However, some concerns remain. Detailed training content has not been accounted for, and current training is insufficient to ensure patient safety [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. A standardized training curriculum for robotic surgery has yet to be established [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn this context, we developed our robotic training curriculum, focusing on residents without experience in open and laparoscopic surgery. Our curriculum was implemented until the residents became independent primary surgeons.\u003c/p\u003e\u003cp\u003eIn this study, we evaluated the usefulness of our training curriculum by comparing the outcomes of RARP performed by residents with the outcomes of those performed by non-resident surgeons. Additionally, we analyzed the impact of the curriculum on surgical outcomes across various procedural components.\u003c/p\u003e"},{"header":"2. Patients and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003e2.1 Patient cohort\u003c/h2\u003e\u003cp\u003eThis was a single-institution retrospective study. Informed consent was obtained from all participants using the opt-out method (Approval No: 240625B). A total of 278 patients with localized prostate cancer underwent RARP at Itabashi Chuo Medical Center between April 2021 and April 2023. Salvage RARP was not included. The patients\u0026rsquo; medical records were reviewed, and 50 patients who underwent RARP performed by a surgeon with extensive laparoscopic surgery experience (certified by JSER as a urological laparoscopic surgeon) were excluded. The remaining 228 patients were included.\u003c/p\u003e\u003cp\u003eAll patients had a pathological diagnosis of prostate cancer before surgery and underwent computed tomography, magnetic resonance imaging, and bone scintigraphy for staging. Eight surgeons performed RARP using the Da Vinci Xi system (Intuitive Surgical, Sunnyvale, CA, USA) with the same techniques and procedures. Three surgeons were not resident and certified as RARP proctors by the JSER (with more than 40 cases of primary surgical experience), while five surgeons were urological residents: two with limited laparoscopic surgery experience (approximately 10 cases of laparoscopic radical nephrectomy) and three with no laparoscopic surgery experience. We defined RARPs performed by non-resident surgeons as non-resident RARPs (nrRARPs) and those performed by residents as resident RARPs (rRARPs). All surgeries performed by residents were conducted under the supervision of non-resident surgeons. The non-resident surgeons partially took over the key parts of the operation if deemed necessary during surgery to ensure patient safety or to avoid compromising oncological and functional outcomes.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\u003ch2\u003e2.2 Propensity score matching\u003c/h2\u003e\u003cp\u003eTo mitigate confounding factors, 53 patients who underwent rRARP were matched with 53 patients who underwent nrRARP in a 1:1 ratio from our cohort of 175 patients without replacement. This matching was based on propensity score matching including age, body mass index (BMI), initial prostate-specific antigen (iPSA) level, and International Society of Urological Pathology (ISUP) biopsy category. We adopted the 2014 ISUP grading system for Gleason grade evaluation [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eWe compared surgical and pathological outcomes between the two groups, including operative time, console time, estimated blood loss, perioperative complications during hospitalization, positive surgical margin rate, and immediate urinary continence. Perioperative outcomes have been reported according to the Clavien\u0026ndash;Dindo grade [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Perioperative complications with Clavien\u0026ndash;Dindo grade\u0026thinsp;\u0026le;\u0026thinsp;2 were minor complications, while those with Clavien\u0026ndash;Dindo grade\u0026thinsp;\u0026ge;\u0026thinsp;3 were severe complications. We removed the urinary catheter on postoperative days 6 or 7 after checking for no leakage from the vesicourethral anastomosis site on cystography. After catheter removal, patients kept a voiding diary, recording urinary parameters such as frequency of urination and the amount of urinary leakage. Immediate urinary continence was defined as the ratio of the 24-h urine loss volume to the total urine volume per day immediately after urinary catheter removal (the sixth or seventh postoperative day). Thus, zero immediate urinary continence referred to full continence without stress urinary incontinence after catheter removal, commonly described as \u0026ldquo;no urine leakage\u0026rdquo;.\u003c/p\u003e\u003cp\u003eWe divided RARP procedure into five parts: (1) bladder takedown to the division of endopelvic fascia, (2) bladder neck transection (anterior approach), (3) seminal vesicle dissection to the division of the urethra, (4) posterior reconstruction to anterior reconstruction, and (5) vesicourethral anastomosis. Perioperative and postoperative variables were analyzed to determine performance differences between the two groups using Fisher\u0026rsquo;s exact test and the Mann\u0026ndash;Whitney \u003cem\u003eU\u003c/em\u003e test. All statistical analyses were performed using R version 4.0.0 (R Foundation for Statistical Computing, Vienna, Austria) and EZR (Saitama Medical Center, Jichi Medical University, Saitama, Japan), graphical user interfaces for R. Statistical significance for all analyses was defined as p\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\u003ch2\u003e2.3 Surgical techniques\u003c/h2\u003e\u003cp\u003eAll RARPs were performed using the same procedure and technique, specifically conventional RARP with a transperitoneal approach, as previously described [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Our procedures included patient positioning, port placement, bladder takedown, division of the endopelvic fascia, bladder neck transection (anterior approach), seminal vesicle dissection, posterior dissection of the prostate, lateral to apical dissection, dorsal vascular complex cutting and ligation, division of the urethra, lymph node dissection (in high-risk cases), posterior reconstruction, vesicourethral anastomosis, and anterior reconstruction. Unilateral antegrade nerve-sparing procedures were performed in nerve-sparing cases; therefore, bilateral nerve-sparing procedures were not performed. Lymph node dissection was performed for high-risk patients based on their life expectancy and oncological profiles. Non-resident surgeons performed all lymph node dissections in rRARP. High-risk patients received neoadjuvant hormonal therapy for 6 months using luteinizing hormone-releasing hormone agonists or antagonists and nonsteroidal antiandrogens (bicalutamide).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003e2.4. Training curriculum\u003c/h2\u003e\u003cp\u003eAll residents received the same training. Our training curriculum included dry-laboratory and theoretical training. Dry-laboratory training used a three-dimensional (3-D) pelvic model (Fasotec, Chiba, Japan) to develop skills for working in a narrow space, including origami training and vesicourethral anastomosis (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Entire dry-laboratory training was conducted in a 30\u0026ordm; Trendelenburg position, consistent with the conditions for RARP. Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e lists the training methods we used and the equipment involved. Residents had to complete over 40 h of dry-laboratory training and participate in more than 20 RARP cases as bedside surgeons before performing RARP as a console surgeon. However, since we believe that 40 h of dry-laboratory training is insufficient, residents continued their training even after they became console surgeons.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eOur dry-laboratory training list\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDry-laboratory training\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eContent\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSkills to improve\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eInstruments used\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eMaterials used\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eOrigami training\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCreate a crane with origami paper\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eDelicate touch without damaging tissues, hand\u0026ndash;eye coordination\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eLarge needle driver x2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2.5 cm square origami paper\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eVesicourethral anastomosis\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePerform vesicourethral anastomosis using a model\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eLearn the steps, needle handling at various angles, hand\u0026ndash;eye coordination\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eLarge needle driver x2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eUrethrovesical Model (Fasotec, Chiba, Japan), 3\u0026ndash;0 Monocryl sutures (14 cm), tied at both ends\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cdiv id=\"Sec7\" class=\"Section3\"\u003e\u003ch2\u003e2.4.1 Origami training\u003c/h2\u003e\u003cp\u003eA 2.5-cm square paper was used to fold an origami crane, which requires gentle and precise manipulation to avoid tearing the paper. This practice can enhance visual\u0026ndash;tactile sensitivity and improve proficiency in gentle forceps manipulation. Since the Da Vinci system, except for the Da Vinci Ⅴ, lacks a sense of touch, beginner surgeons may unintentionally damage organs with forceps, leading to major complications. Developing visual\u0026ndash;tactile sensitivity helps prevent traction injuries to key muscles, such as the puboperineal muscles and urethral sphincter, as well as to nerves, which is crucial for achieving optimal functional outcomes [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec8\" class=\"Section3\"\u003e\u003ch2\u003e2.4.2 Vesicourethral anastomosis\u003c/h2\u003e\u003cp\u003eVesicourethral anastomosis training used the Urethrovesical Model (Fasotec, Chiba, Japan) to simulate practical surgical conditions. Both training sessions enhanced hand\u0026ndash;eye coordination, bilateral coordinated movement, and suturing skills. We performed the Van Velthoven single-knot running suture with bidirectional 3\u0026thinsp;\u0026minus;\u0026thinsp;0 monofilament. The method for holding the needle and placing sutures is standardized and must be followed in practice. Therefore, every surgeon in our hospital performs vesicourethral anastomosis in the same manner. The goal is to complete the anastomosis within 10 min.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec9\" class=\"Section3\"\u003e\u003ch2\u003e2.4.3 Video lecture\u003c/h2\u003e\u003cp\u003eTheoretical training was conducted via online meetings. A senior doctor taught surgical anatomy and procedures to multiple residents while showing surgical videos. After each case, the senior doctor reviewed the residents\u0026rsquo; surgeries. In addition to discussing the residents\u0026rsquo; thought processes during each surgical procedure, the senior doctor always reviewed each resident\u0026rsquo;s case and shared suggestions for improvement. The meeting videos were stored with patient personal details hidden, allowing residents to access and review them repeatedly.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"3. Results","content":"\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003e3.1 Baseline characteristics after propensity score matching\u003c/h2\u003e\u003cp\u003eAfter 1:1 propensity score matching, the two groups exhibited similar preoperative characteristics, including age, BMI, iPSA, biopsy ISUP category, estimated prostate volume, PSA density, clinical tumor stage, and National Comprehensive Cancer Network risk group (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eComparison of preoperative characteristics between non-resident and resident performed Robot-assisted radical prostatectomy (RARP) after 1:1 propensity score matching\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMeasured parameter\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNon-resident RARP\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eResident RARP\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003ep value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eNumber of patients\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e53\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e53\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAge at surgery (year), median (IQR)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e70.0 (65.0, 74.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e69.0 (65.0, 73.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.567\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eBody Mass Index (kg/m\u003c/b\u003e\u003csup\u003e\u003cb\u003e2\u003c/b\u003e\u003c/sup\u003e\u003cb\u003e), median (IQR)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e24.2 (22.9, 25.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e24.1 (22.1, 25.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.445\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eInitial PSA (ng/mL), median (IQR)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6.55 (5.10, 9.10)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6.16 (4.90, 11.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.698\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eBiopsy International Society of Urological Pathology Grade, n (%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.776\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eGrade 1\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5 (9.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e9 (17.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.776\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eGrade 2\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e10 (18.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e12 (22.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eGrade 3\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e12 (22.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e10 (18.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eGrade 4\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e17 (32.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e14 (26.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eGrade 5\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e9 (17.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8 (15.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eEstimate prostate volume (mL)\u003c/b\u003e\u003csup\u003e\u003cb\u003ea\u003c/b\u003e\u003c/sup\u003e, \u003cb\u003emedian (IQR)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e40.0 (35.0, 55.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e40.0 (30.0, 45.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.093\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePSA density, median (IQR)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.16 (0.11, 0.25)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.16 (0.12, 0.30)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.431\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ecT stage, n (%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.169\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ecT1\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8 (15.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e10 (18.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ecT2\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e39 (73.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e42 (79.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ecT3\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6 (11.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (1.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ecT4\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0 (0.00)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 (0.00)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eNational Comprehensive Cancer Network risk group, n (%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eLow\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5 (9.43)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6 (11.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.405\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eIntermediate\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e19 (35.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e25 (47.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eHigh\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e29 (54.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e22 (41.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003eData are presented as median values with IQRs or number of patients with percentages.\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003eAbbreviations: cT clinical Tumor, IQR inter quartile range, PSA prostate-specific antigen, RARP Robot-assisted radical prostatectomy\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003csup\u003e\u003cb\u003ea\u003c/b\u003e\u003c/sup\u003e Estimated prostate volume was calculated by staging CT before neoadjuvant hormone therapy.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e shows the perioperative characteristics and surgical outcomes between the non-resident groups and resident groups who performed RARP after 1:1 propensity score matching. Regarding perioperative characteristics, there were no significant differences in the rates of neoadjuvant hormone therapy and pelvic lymph node dissection (PLND) between the two groups.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eComparison of perioperative characteristics and surgical outcomes between non-resident and resident performed robot-assisted radical prostatectomy (RARP) after 1:1 propensity score matching\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMeasured parameter\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNon-resident RARP\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eResident RARP\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003ep value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eNumber of patients\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e53\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e53\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"1\" nameend=\"c5\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eNeoadjuvant hormone therapy, n (%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e24 (45.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e25 (47.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003e1.00\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePast history of TURP, n (%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4 (7.54)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 (0.00)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003e0.118\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePast history of abdominal surgery, n (%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e11 (20.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e15 (28.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003e0.499\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eNerve-sparing procedure, n (%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6 (11.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4 (7.54)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003e0.741\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePLND, n (%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e13 (24.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e16 (30.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003e0.663\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eExtended PLND, n (%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7 (13.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8 (15.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003e1.00\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePartial PLND, n (%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6 (11.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8 (15.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003e0.775\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eOperative time (min), median (IQR)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e213 (183, 238)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e249 (225, 283)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eConsole time (min), median (IQR)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e170 (143, 194)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e211 (185, 237)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eConsole time without PLND (min), median (IQR)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e160 (141, 179)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e199 (182, 217)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003e(1) Bladder takedown to division of endopelvic fascia\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e30.0 (25.0, 38.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e45.0 (38.8, 50.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003e(2) Bladder neck transection\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e15.0 (12.0, 21.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e20.0 (16.8, 28.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003e(3) Seminal vesicle dissection to division of the urethra\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e49.0 (40.0, 60.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e66.0 (54.0, 77.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003e(4) Posterior reconstruction to anterior construction\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e54.0 (45.0, 69.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e63.0 (54.8, 71.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003e0.018\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003e(5) Vesicourethral anastomosis\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e14.0 (11.0, 19.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e17.0 (14.0, 22.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003e0.082\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eEstimated blood loss (mL), median (IQR)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e200 (100, 300)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e170 (100, 300)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003e0.683\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSpecimen Weight (g), median (IQR)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e43.0 (32.0, 57.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e38.0 (31.0, 49.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003e0.307\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003epT stage, n (%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003epT2\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e41 (77.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e45 (84.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003e0.326\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003epT3a\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8 (15.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6 (11.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003epT3b\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4 (7.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (1.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eExtraprostatic extension, n (%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e11 (20.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7 (13.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003e0.523\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePositive surgical margins, n (%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eOverall\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7 (13.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4 (7.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003e0.526\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAmong pT2\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 (4.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3 (6.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003e1.00\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAmong pT3\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5 (41.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (14.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003e0.333\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eImmediate urinary incontinence rate, n (%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003e0%\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e23 (43.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e23 (43.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003e1.00\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;5%\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e36 (67.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e33 (62.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003e0.684\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;10%\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e40 (75.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e39 (73.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003e1.00\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePerioperative complication, n (%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eClavien\u0026ndash;Dindo grade II\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0 (0.00)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 (0.00)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003e1.00\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eClavien\u0026ndash;Dindo grade III\u003c/b\u003e \u003csup\u003e\u003cb\u003ea\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0 (0.00)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (1.88)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003e1.00\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eClavien\u0026ndash;Dindo grade IV and V\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0 (0.00)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 (0.00)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003e1.00\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"5\"\u003eData were presented as median values with IQRs or numbers of patients with percentages.\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"5\"\u003eAbbreviations: IQR inter quartile range, PLND pelvic lymph node dissection, pT pathological Tumor, RARP Robot-assisted radical prostatectomy, TURP transurethral resection of prostate\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003csup\u003e\u003cb\u003ea\u003c/b\u003e\u003c/sup\u003e Rectal injury\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003e3.2 Surgical and pathological outcomes\u003c/h2\u003e\u003cp\u003eThe rRARP group took 36, 41, and 39 min longer in terms of total operative time (249 vs. 213 min; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), console time (211 vs. 170 min; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and console time without PLND (199 vs. 160 min; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), respectively. To investigate which parts required more time, we further divided the procedures into five parts and compared the two groups with regard to each part. The surgeons in the rRARP group took 15, 5, 17, 9, and 3 min longer for the procedure of bladder takedown to the division of endopelvic fascia (45 vs. 30 min; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), that of bladder neck transection (anterior approach) (20 vs. 15 min; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), that of seminal vesicle dissection to the division of the urethra (66 vs. 49 min; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), that of posterior reconstruction to anterior reconstruction (63 vs. 54 min; p\u0026thinsp;=\u0026thinsp;0.018), and that of vesicourethral anastomosis (17 vs. 14 min; p\u0026thinsp;=\u0026thinsp;0.082), respectively (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eA, B, C, and D). No significant difference was observed in the procedure of vesicourethral anastomosis (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eE).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eRegarding pathological outcomes, no significant difference existed in the pathological T stage, extraprostatic extension, or positive margins across all T stages, including the pathological T2 and T3 groups. Immediate urinary incontinence was comparable between the two groups. The rates of Clavien\u0026ndash;Dindo classification grades II and III were comparable; no severe perioperative complications (Clavien\u0026ndash;Dindo classification grades IV or V) were noted during hospitalization. One case of a grade III complication in the rRARP group involved a rectal injury, which occurred when the suction tube, handled by the bedside surgeon, inadvertently punctured the rectum during posterior dissection. It required two-layer suturing to close the small hole. The postoperative course was uneventful and similar to that of the other patients.\u003c/p\u003e\u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cp\u003ePrevious studies evaluating different training methods in urology have primarily focused on skill acquisition rather than on directly demonstrating improved outcomes and reduced complications [\u003cspan additionalcitationids=\"CR7 CR8\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. In contrast, our training program included both dry-laboratory and theoretical training and has proven effective in preparing residents to perform RARP. Additionally, we focused on the effectiveness of training by comparing surgical outcomes. Various training methods aimed at developing both technical and non-technical skills necessary for performing robotic surgery safely and effectively have been reported. The emphasis is placed on a structured, comprehensive approach that combines theoretical knowledge, simulated practice, and supervised clinical experience before allowing independent practice [\u003cspan additionalcitationids=\"CR5 CR6\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Our training curriculum incorporated these components as well. Herein, we evaluated the usefulness of our training curriculum by comparing outcomes of RARP performed by residents (rRARP group) with those of that performed by non-resident surgeons (nrRARP group).\u003c/p\u003e\u003cp\u003eThe surgeons in the rRARP group required significantly longer operative and console times than those in the nrRARP group, likely owing to their need to develop proficiency in robotic surgical techniques. This was particularly evident in the procedures of bladder takedown to the division of the endopelvic fascia, bladder neck transection, and seminal vesicle dissection to urethra division. These procedures exhibited significant variability from case to case. We needed to tailor surgical techniques based on the degree of periprostatic adhesion, prostate shape, and oncological profile, which required extensive surgical experience. However, this experience, traditionally gained through open or laparoscopic surgery, was lacking among residents, who needed some time to adapt to the variability among cases.\u003c/p\u003e\u003cp\u003eBy contrast, there were no significant differences in the vesicourethral anastomosis procedure. This result is likely to be attributed to a well-designed simulation model. The high quality and reproducibility of the anastomosis model allow residents to practice repeatedly. Because the residents followed predetermined needle handling and suturing techniques using uniform sutures and needles that matched real procedures, they could perform anastomosis during surgery as practiced in dry-laboratory training. Additionally, anastomosis shows little individual variation across cases. The variability in anastomosis cases is less significant than that in periprostatic dissection, making it more conducive to consistent practice.\u003c/p\u003e\u003cp\u003eIn terms of postoperative outcomes, we found no significant differences in pathological T stage, extraprostatic extension, positive surgical margins, the incidence of perioperative complications classified as Clavien\u0026ndash;Dindo grades II and III, or immediate urinary continence between the two groups. These data indicate that, despite longer operative times (which did not exceed 4 h), the residents safely achieved similar oncological and urinary continence outcomes as the non-resident surgeons.\u003c/p\u003e\u003cp\u003eThis study had a few limitations. First, we assigned only non-challenging cases to residents, limiting them to perform procedures on patients with a prostate volume of 40 mL or less, those without significant median lobe enlargement, and those without nerve-sparing procedures. Conversely, non-resident surgeons performed procedures on patients with high BMI, history of abdominal surgery or TURP, large prostate volumes, median lobe enlargement, or nerve-sparing procedure, which required more advanced skills [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Our patient selection contributed to the feasible outcomes of rRARP and enhanced the efficacy of residents\u0026rsquo; training. Second, difficult situations, even in non-challenging cases, were managed by the attending non-resident surgeon. Certain parts of rRAPR were taken over by non-resident surgeons as needed. Although the decision for non-resident surgeons to take over surgical aspects of the rRARP introduced intervention bias, non-resident surgeons\u0026rsquo; supervision and guidance played a role in ensuring the safety and comparable outcomes of rRARP. Third, our findings were limited by the study\u0026rsquo;s retrospective nature and small sample size.\u003c/p\u003e\u003cp\u003eDespite these limitations, our data underscored the value of structured resident training programs, particularly repeated training with a more practical model, in improving surgical proficiency. Our study findings highlighted the importance of well-designed surgical training models. However, the current model remains inadequate owing to its high cost, limited time, and restricted availability of training facilities. While the anastomosis model proved to be reproducible and useful for practice, most other models are not practical at a functional level. Apart from the anastomosis model, we were unable to use other well-designed models, making it challenging to simulate each RARP procedure owing to the complexity of clinical anatomy in bladder takedown, bladder neck transection, seminal vesicle dissection, and urethral division. Nevertheless, various novel surgical models and simulators, such as virtual reality models and 3-D-printed organ models, are currently under development, offering hope that new technologies will help overcome these challenges [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Although we do not consider experience in open or laparoscopic surgery to be unnecessary for residents, our results suggest that such experience can be supplemented through appropriate and structured training. As it becomes increasingly difficult to ensure that every resident gains sufficient experience in open or laparoscopic procedures, we hope that our training program will contribute, even in part, to bridging that gap.\u003c/p\u003e\u003cp\u003eIn conclusion, our study demonstrates that residents can perform RARP safely with acceptable surgical outcomes compared to non-resident surgeons, despite longer operative times. The high reproducibility of the anastomosis model allowed the residents to reduce operative times through practice. The development of accessible and more practical training models is essential, particularly for robotic surgical training for residents lacking prior experience in open or laparoscopic surgeries.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to thank Editage (http://www.editage.com) for English language editing.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no conflict of interest.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data supporting the findings of this study are available from the corresponding author upon a reasonable request. The datasets generated and/or analyzed during this study are available from the corresponding author on a reasonable request.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSunao Nohara was the lead author involved with the conception of the work, data collection, statistical analysis, and article synthesis with substantial support from Yu Ozawa. Keisuke Aoki, Shin Koike, Kei Ushijima, Toshiaki Kayaba, Masumi Yamada, Yu Odagaki, Hideo Sakamoto, and Kunihiko Yoshioka contributed to the data collection. Choichiro Ozu and Kunihiko Yoshioka supervised the findings of the study. All authors substantially contributed to the revision of the manuscript and have approved the final version of the manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe protocol for this research project was approved by a suitably constituted Research Ethics Committee of the institution, and it conforms to the provisions of the Declaration of Helsinki (Institutional Review Board, Approval No. 240625B.).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInformed consent\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInformed consent was obtained from all participants using the opt-out method.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eJapanese Society of Endourology and Robotics (2025) Urological robotic-assisted surgery proctor certification program. Published online July 1, 2024. 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J Robot Surg 16:749\u0026ndash;763. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s11701-021-01302-8\u003c/span\u003e\u003cspan address=\"10.1007/s11701-021-01302-8\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":true,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"international-journal-of-clinical-oncology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ijco","sideBox":"Learn more about [International Journal of Clinical Oncology](http://link.springer.com/journal/10147)","snPcode":"10147","submissionUrl":"https://www.editorialmanager.com/ijco/default2.aspx","title":"International Journal of Clinical Oncology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Education, Propensity Score, Prostate Cancer, Robotic Surgical Procedures","lastPublishedDoi":"10.21203/rs.3.rs-7066257/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7066257/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eWe developed a robot-assisted training curriculum for urology residents with limited experience in open and laparoscopic surgeries. In this retrospective single-center study, we aimed to evaluate our curriculum by comparing surgical outcomes of robot-assisted radical prostatectomy performed by residents enrolled in the curriculum with those of procedures performed by experienced surgeons.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eFifty-three patients whose robot-assisted radical prostatectomy was performed by urology residents were propensity score-matched using clinicopathological characteristics to patients whose robot-assisted radical prostatectomy was performed by experienced surgeons. Surgical and pathological outcomes were compared between groups, including estimated blood loss, operative time, perioperative complication rates, positive surgical margins, and immediate urinary continence. Residents were initially trained in robot-assisted surgery. Our training program included video lectures and dry-laboratory exercises with three-dimensional pelvic models, origami training, and vesicourethral anastomosis simulation.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eEstimated blood loss and complication rates were comparable between groups. Bladder takedown and seminal vesicle dissection significantly prolonged the operative time in the resident group, which was 1.16 times longer (median 249 vs. 213 min; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Notably, vesicourethral anastomosis time was the only procedure with comparable time between groups (17 vs. 14 min; p\u0026thinsp;=\u0026thinsp;0.082). There were no significant differences in perioperative complication rates, positive surgical margin rates, or immediate urinary continence.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eTrained residents performed robot-assisted radical prostatectomy safely with acceptable surgical outcomes, despite longer operative times. Simulation-based training enables residents to perform procedures within a timeframe comparable to that of experienced surgeons; therefore, well-designed surgical models are needed for training purposes.\u003c/p\u003e","manuscriptTitle":"Comparison of Surgical Outcomes of Robot-assisted Radical Prostatectomy between Residents under our Training Curriculum and Experienced Surgeons: A Propensity Score-matched Analysis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-14 11:40:02","doi":"10.21203/rs.3.rs-7066257/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revisions","date":"2025-07-31T05:19:03+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"","date":"2025-07-10T23:37:27+00:00","index":0,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-07-10T07:55:48+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-07-09T11:58:44+00:00","index":"","fulltext":""},{"type":"submitted","content":"International Journal of Clinical Oncology","date":"2025-07-07T10:05:23+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"international-journal-of-clinical-oncology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ijco","sideBox":"Learn more about [International Journal of Clinical Oncology](http://link.springer.com/journal/10147)","snPcode":"10147","submissionUrl":"https://www.editorialmanager.com/ijco/default2.aspx","title":"International Journal of Clinical Oncology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"6207ae90-e745-428f-ba41-a001a4cf2f2a","owner":[],"postedDate":"July 14th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-04-13T16:00:09+00:00","versionOfRecord":{"articleIdentity":"rs-7066257","link":"https://doi.org/10.1007/s10147-026-03027-w","journal":{"identity":"international-journal-of-clinical-oncology","isVorOnly":false,"title":"International Journal of Clinical Oncology"},"publishedOn":"2026-04-11 15:57:30","publishedOnDateReadable":"April 11th, 2026"},"versionCreatedAt":"2025-07-14 11:40:02","video":"","vorDoi":"10.1007/s10147-026-03027-w","vorDoiUrl":"https://doi.org/10.1007/s10147-026-03027-w","workflowStages":[]},"version":"v1","identity":"rs-7066257","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7066257","identity":"rs-7066257","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}