Learning Curve and Video-Based Technical Assessment of a Standardized Vesicourethral Anastomosis in Novice Robotic...

Background/Objectives: Vesicourethral anastomosis (VUA) is one of the most technically demanding steps of robot-assisted radical prostatectomy (RARP) and may influence perioperative outcomes and early urinary continence recovery. Objective assessment of technical performance during the learning curve remains limited. We evaluated the learning curve and technical performance of a standardized VUA technique among novice robotic surgeons using a structured video-based assessment. Methods: In this retrospective single-center study, 100 consecutive patients undergoing RARP performed by four novice robotic surgeons were analyzed. All surgeons used the same standardized VUA technique. Operative videos were reviewed and assessed using a modified Robotic Anastomosis Competency Evaluation (RACE) score. Learning-curve trends were analyzed using LOWESS smoothing and mixed-effects regression models. The primary outcome was VUA time. Secondary outcomes included technical performance, anastomosis-related complications, catheterization duration, and urinary continence recovery. Results: A total of 100 procedures were included (25 per surgeon). Increasing surgical experience was significantly associated with shorter VUA time (β = -6.93, 95% CI -7.42 to -6.44; p < 0.001) and higher modified RACE scores (β = 4.99, 95% CI 4.55-5.43; p < 0.001). Median VUA time decreased from 32 min (IQR 29-37) during the early phase to 19 min (IQR 18-20.3) during the late phase (p < 0.001), while median RACE score improved from 13 (IQR 11-15) to 22 (IQR 21-23) (p < 0.001). Positive leak tests decreased from 37.5% to 12.5% (p = 0.03), and the need for additional stitches decreased significantly (p < 0.001). Catheterization time was reduced from 8 to 6 days (p < 0.001). Early urinary continence improved from 37.5% to 65% at 30 days (p = 0.025) and from 60% to 85% at 90 days (p = 0.04), whereas differences were no longer significant at longer follow-up. Conclusions: Novice robotic surgeons performing a standardized VUA technique showed progressive improvements in procedural efficiency and technical performance during their early learning curve. These findings describe technical progression within a standardized operative framework but do not establish an independent effect of standardization itself. Enhanced technical proficiency was accompanied by improved perioperative parameters and a faster recovery of early urinary continence. Video-based assessment may represent a valuable tool for objective monitoring of skill acquisition during robotic surgical training.