Laparoscopy and Robotics Temporal Relationship Between Positive Margin Rate After Laparoscopic Radical Prostatectomy and Surgical Training Jay B. Page, Daniel L. Davenport, Raman Unnikrishnan, Paul L. Crispen, Ramakrishna Venkatesh, and Stephen E. Strup OBJECTIVES To evaluate the potential impact of the experience of the first assistant on the positive surgical margin rate (PSMR) after laparoscopic radical prostatectomy (LRP). The impact of training surgical residents and fellows on patient outcomes is difficult to quantify. METHODS A single-institution prospective database of 303 patients who underwent LRP between 2003 and 2008 was evaluated. The potential impact of the experience of the first assistant on the PSMR was evaluated by examining the relationship between the PSMR and the time of the academic year. Multivariable logistic regression analysis was used to adjust for patient age, Gleason’s sum, tumor density, and pathologic stage. RESULTS Overall positive margin rate was 18.2%. Positive margin rate for July and August (14/45, 31.1%) was significantly higher than for the remaining 10 months (41/258, 15.9%) P = .015. The increased risk of positive margin in July/August remained significant after adjusting for age, Gleason’s sum, tumor density, and pathologic stage (OR 2.65, 95% CI 1.21–5.79, P = .015) CONCLUSIONS LRP performed with the first assistant in the first 2 months of the academic training year have a significantly higher PSMR. UROLOGY 77: 626 – 630, 2011. © 2011 Elsevier Inc. S ince the first report of laparoscopic radical prosta- tectomy (LRP), minimally invasive techniques for prostate extirpation have proliferated. 1 Educa- tional models for teaching these techniques have been an active area of investigation. 2-4 However, most studies have focused on the primary surgeon’s experience and learning curve on patient outcomes without considering the potential impact of the experience of the first assis- tant. 3,5 A large cohort of LRP showed successive im- provement in 5-year biochemical recurrence if the pri- mary surgeon had performed more than 10, 250, or 750 procedures. 6 Improved surgical margin status has also been reported after open radical prostatectomy when the primary surgeon had performed 10 vs 250 prior cases. 7 Although the experience of the primary surgeon clearly impacts outcomes, little is known regarding the effect of surgical trainees on outcomes after LRP. Surgical trainees in the beginning of an academic year are expected to be less proficient and acclimatized to newly assigned surgical tasks and responsibilities. We sought to evaluate the impact of surgical trainees on the positive surgical margin rate (PSMR) of LRP before their performing significant portions of the procedure based on the time of year. PATIENTS AND METHODS After institutional review board approval, we reviewed prospec- tively collected data from laparoscopic radical prostatectomies performed without robotic assistance at a single academic ter- tiary referral center between July 2003 and June 2008. Tumors were classified based on the 1997 tumor-node-metastasis clas- sification system and graded by Gleason’s sum. Tumor density was determined by percent tumor involvement on pathologic examination. Positive margins were defined by any malignant cells abutting the inked surgical margin. Operative time in- cluded time from skin incision until completion of skin closure. Estimated blood loss was determined by the primary surgeon by subtracting the volume of irrigant used from the volume con- tained in the aspiration canister. All procedures were performed using a modified standardized transperitoneal laparoscopic approach described previously. 8 Supraumbilical and left lower quadrant 12-mm ports were placed, as were 5-mm ports in the left and right lower quad- rants. Patients were placed in steep Trendelenburg position. The camera was controlled by the primary surgeon using a voice activated Aesop (Intuitive Surgical, Sunnyvale, CA) device. An anterior approach was used, the space of Retzius was devel- oped, and the dorsal venous complex was ligated using polyg- lactin sutures. Bladder neck, vascular pedicles, seminal vesicle, and vasa deferentia dissections were performed using a har- monic scalpel. When additional anterior retraction was needed, From the Division of Urology, University of Kentucky, Lexington, KY; and Department of Surgery, University of Kentucky, Lexington, KY. R. Venkatesh is a speaker for Pfizer, Inc. Reprint requests: Jay B. Page, M.D., Clinical Instructor, Chandler Medical Center, 800 Rose Street, MS283. Lexington, KY. E-mail: jay.page@uky.edu Submitted: March 16, 2010, accepted (with revisions): June 29, 2010 626 © 2011 Elsevier Inc. 0090-4295/11/$36.00 All Rights Reserved doi:10.1016/j.urology.2010.06.073