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Development of a surgical competency assessment tool for sentinel lymph node dissection by minimally invasive surgery for endometrial cancer
  1. Kristen Moloney1,
  2. Monika Janda2,
  3. Michael Frumovitz3,
  4. Mario Leitao4,
  5. Nadeem R Abu-Rustum4,
  6. Emma Rossi5,
  7. James L Nicklin6,7,
  8. Marie Plante8,
  9. Fabrice R Lecuru9,10,
  10. Alessandro Buda11,12,
  11. Andrea Mariani13,
  12. Yee Leung14,
  13. Sarah Elizabeth Ferguson15,16,
  14. Rene Pareja17,18,
  15. Rainer Kimmig19,
  16. Pearl Shuang Ye Tong20,
  17. Orla McNally21,22,
  18. Naven Chetty23,
  19. Kaijiang Liu24,
  20. Ken Jaaback25,
  21. Julio Lau26,27,
  22. Soon Yau Joseph Ng28,
  23. Henrik Falconer29,30,
  24. Jan Persson31,32,
  25. Russell Land1,7,
  26. Fabio Martinelli33,
  27. Andrea Garrett1,
  28. Alon Altman34,35,
  29. Adam Pendlebury36,
  30. David Cibula37,38,
  31. Roberto Altamirano39,40,
  32. Donal Brennan41,42,
  33. Thomas Edward Ind43,44,
  34. Cornelis De Kroon45,
  35. Ka Yu Tse46,
  36. George Hanna47 and
  37. Andreas Obermair48,49
  1. 1Gynaecologic Oncology, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
  2. 2Centre for Health Services Research, The University of Queensland Faculty of Medicine, Brisbane, Queensland, Australia
  3. 3Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
  4. 4Gynecology Service Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
  5. 5Obstetrics and Gynecology, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
  6. 6Gynaecological Oncology, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
  7. 7Faculty of Medicine, The University of Queensland, St Lucia, Queensland, Australia
  8. 8Gynecology Oncology Service, Centre Hospitalier Universitaire de Québec-Université Laval, Quebec, Quebec, Canada
  9. 9Surgical Oncology, Institute Curie, Paris, France
  10. 10Surgical Oncology Department for Breast and Gynecology, Universite de Paris, Paris, Île-de-France, France
  11. 11Department of Obstetrics and Gynecology, Università degli Studi Milano-Bicocca, San Gerardo Hospital, Monza, Italy
  12. 12Division of Gynecologic Oncology Italy, Ospedale Michele e Pietro Ferrero, Verduno (CN), Italy
  13. 13Gynecologic Surgery, Department of Obstetrics and Gynecology, Mayo Clinic Rochester, Rochester, Minnesota, USA
  14. 14Obstetrics and Gynaecology, The University of Western Australia Faculty of Health and Medical Sciences, Perth, Western Australia, Australia
  15. 15Gynecologic Oncology, University Health Network, Toronto, Ontario, Canada
  16. 16Obstetrics and Gynaecology, University of Toronto, Toronto, Ontario, Canada
  17. 17Gynecologic Oncology, Instituto Nacional de Cancerologia, Bogota, Colombia
  18. 18Gynecologic Oncology, Clínica De Oncología Astorga, Medellín, Colombia
  19. 19Gynecology and Obstetrics, University of Essen, Essen, Germany
  20. 20Gynaecologic Oncology, National University Health System, Singapore
  21. 21Obstetrics and Gynaecology, Royal Women's Hospital, Parkville, Victoria, Australia
  22. 22Victorian Comprehensive Cancer Centre, University of Melbourne, Parkville, Victoria, Australia
  23. 23Gynaecologic Oncology, Mater Health Services Brisbane, South Brisbane, Queensland, Australia
  24. 24Gynecology and Obstetrics, Shanghai Jiao Tong University School of Medicine Affiliated Renji Hospital, Shanghai, China
  25. 25Gynaecologic Oncology, John Hunter Hospital, New Lambton Heights, New South Wales, Australia
  26. 26Gynecology Oncology, Hospital General San Juan de Dios, Guatemala, Guatemala
  27. 27Gynecology Oncology, University of San Carlos de Guatemala Faculty of Medical Sciences, Guatemala, Guatemala
  28. 28Obstetrics and Gynaecology, National University of Singapore, Singapore
  29. 29Women's and Children's Health, Karolinska Institute, Stockholm, Sweden
  30. 30Women's and Children's Health, Karolinska University Hospital, Stockholm, Sweden
  31. 31Obstetrics and Gynaecology, Skanes Universitetssjukhus Lund, Lund, Skåne, Sweden
  32. 32Clinical Sciences, Obstetrics and Gynaecology, Lund University Faculty of Medicine, Lund, Sweden
  33. 33Gynaecologic Oncology, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
  34. 34Gynecologic Oncology, University of Manitoba, Winnipeg, Manitoba, Canada
  35. 35Gynecologic Oncology, CancerCare Manitoba, Winnipeg, Manitoba, Canada
  36. 36Gynaecological Oncology, Mercy Hospital for Women, Heidelberg, Victoria, Australia
  37. 37Gynecology and Obstetrics, Charles University First Faculty of Medicine, Praha, Praha, Czech Republic
  38. 38Gynecology and Obstetrics, General University Hospital in Prague, Praha, Czech Republic
  39. 39Gynecology Oncology, Universidad de Chile, Santiago de Chile, Chile
  40. 40Gynecology Oncology, Hospital Clinico San Borja Arriaran, Santiago, Chile
  41. 41Gynaecology Oncology, Mater Misericordiae University Hospital, Dublin, Ireland
  42. 42School of Medicine, University College Dublin, Dublin, Ireland
  43. 43Gynaecological Oncology, Royal Marsden NHS Foundation Trust, London, UK
  44. 44Gynaecology, St George's University of London, London, UK
  45. 45Gynecology, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
  46. 46Obstetrics and Gynaecology, University of Hong Kong Li Ka Shing Faculty of Medicine, Hong Kong, Hong Kong
  47. 47Surgery and Cancer, Imperial College London, London, UK
  48. 48Center for Clinical Research, Faculty of Medicine, University of Queensland, Herston, Queensland, Australia
  49. 49Queensland Centre for Gynaecologic Cancer Research, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
  1. Correspondence to Professor Andreas Obermair, Gynaecological Oncology, University of Queensland Queensland Centre for Gynaecological Cancer Research, Herston, QLD 4029, Australia; ao{at}


Introduction Sentinel lymph node dissection is widely used in the staging of endometrial cancer. Variation in surgical techniques potentially impacts diagnostic accuracy and oncologic outcomes, and poses barriers to the comparison of outcomes across institutions or clinical trial sites. Standardization of surgical technique and surgical quality assessment tools are critical to the conduct of clinical trials. By identifying mandatory and prohibited steps of sentinel lymph node (SLN) dissection in endometrial cancer, the purpose of this study was to develop and validate a competency assessment tool for use in surgical quality assurance.

Methods A Delphi methodology was applied, included 35 expert gynecological oncology surgeons from 16 countries. Interviews identified key steps and tasks which were rated mandatory, optional, or prohibited using questionnaires. Using the surgical steps for which consensus was achieved, a competency assessment tool was developed and subjected to assessments of validity and reliability.

Results Seventy percent consensus agreement standardized the specific mandatory, optional, and prohibited steps of SLN dissection for endometrial cancer and informed the development of a competency assessment tool. Consensus agreement identified 21 mandatory and three prohibited steps to complete a SLN dissection. The competency assessment tool was used to rate surgical quality in three preselected videos, demonstrating clear separation in the rating of the skill level displayed with mean skills summary scores differing significantly between the three videos (F score=89.4; P<0.001). Internal consistency of the items was high (Cronbach α=0.88).

Conclusion Specific mandatory and prohibited steps of SLN dissection in endometrial cancer have been identified and validated based on consensus among a large number of international experts. A competency assessment tool is now available and can be used for surgeon selection in clinical trials and for ongoing, prospective quality assurance in routine clinical care.

  • sentinel lymph node
  • surgical oncology
  • surgical procedures
  • operative
  • uterine cancer
  • endometrial neoplasms

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  • GH and AO are joint senior authors.

  • Twitter @frumovitz, @leitaomd, @drjuliolau, @DrFMartinelli, @ThomasInd

  • Contributors KM, AO, MJ, and GH contributed to the design of the trial. KM, AO, and MJ contributed to manuscript writing. All authors contributed to data acquisition, interpretation of data, revising the draft for intellectual content, final approval of the version to be published, and agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy and integrity of any part of the work were appropriately investigated and resolved.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial, or not-for-profit sectors.

  • Competing interests AO reports grants and personal fees from Surgical Performance PTY LTD, grants from Medtronic, outside the submitted work; NRA-R reports grants from Stryker/Novadaq, outside the submitted work; MF reports grants from Astra Zeneca, grants from Tesaro/GSK, grants and personal fees from Stryker, grants from Biom’Up, outside the submitted work; ML reports Ad hoc consulting from Intuitive Surgical, serves on advisory board for Ethicon, partial grant support from NIH/NCI Memorial Sloan Kettering Cancer Center Support, outside the submitted work; TEI reports personal fees from Medtronic, personal fees from Intuitive Surgical, outside the submitted work; RK reports personal fees from Intuitive Surgical Inc., personal fees from Medtronic, personal fees from Medicaroid, outside the submitted work, and President of SERGS and Council Member of IGCS; HF reports personal fees from Intuitive Surgical Inc, outside the submitted work; JP reports personal fees from Intuitive Surgical Inc., outside the submitted work; AA reports grants and a site PI, speaker fees and serves on advisory board for Astrazeneca, serves on the advisory board for GSK, grants and grats and site Co-PI and speaker fees from Merck, speaker fees from Sanofi, grants from Pfizer, grants from Clovis, grants from CancerCare Manitoba Foundation, grants from Canadian Clinical Trials group, outside the submitted work.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available upon reasonable request. All data relevant to the study are included in the article or uploaded as supplementary information. The authors confirm that the data supporting the findings of this study are available within the article and its supplementary materials.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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