Development of a standardised training curriculum for robotic surgery: a consensus statement from an international multidisciplinary group of experts

Virtual reality simulations in robotic surgery training: a systematic review and meta-analysis

OBJECTIVE

To compare VR simulations with other training methods regarding improvements in objective assessment scores and task completion times.

METHOD

A database search was conducted on 20 May 2024 across Central, MEDLINE, EMBASE, Web of Science, and Scopus. Included were randomised controlled trials comparing VR simulations to other training methods, assessing objective scores and task times. The Risk of Bias-2 tool was used for bias assessment.

RESULTS

Eighteen studies were included. VR significantly improved objective scores (n = 339, SMD 1.04, 95% CI 0.40-1.69, P = 0.002) and reduced task completion times (n = 357, SMD of -1.08, 95% CI of as - 2.05 to - 0.12, P = 0.03) compared to no additional training. VR was as effective as dry lab training for improving scores (n = 213, SMD -0.47, 95% CI - 1.34 to 0.41, P = 0.30) and task times (n = 98, SMD - 0.37, 95% CI - 1.51 to 0.78, P = 0.53). However, one study found wet lab training significantly reduced task times compared to VR (n = 20, SMD of 1.7, 95% CI of 0.65-2.76, P = 0.002). No significant differences were found when VR alone was compared to VR with expert advice.

CONCLUSION

VR is more effective than no additional training and is as effective as dry lab training in robotic skill acquisitions. Therefore, VR is effective in enhancing robotic surgery skills and warrants an expanded role in surgical training programmes.

Robotic Surgery in Thoracic Training Programs: A National Needs Assessment

BACKGROUND

Cardiothoracic surgical trainees perceive a need for more instruction and exposure to robotic-assisted thoracoscopic surgery during their training. We sought to assess use and trainee exposure to robotic surgery in thoracic residency programs to identify areas for improvement.

METHODS

A voluntary electronic survey of 10 questions was distributed to surgeons working in all thoracic surgery residency programs in the United States. The survey asked respondents to provide the size of the residency, the availability and use of robots, and the trainee's adoption of robotic surgery in their practice after graduation. Multivariable logistic regression was performed.

RESULTS

Of a total of 76 cardiothoracic surgery training programs, surgeons from 69 training programs (90.8%) completed the survey. Most pulmonary lobectomy was performed using robotic surgery (55%). Approximately half of the training programs (35 of 69) have a formal robotic curriculum for the residents. Of 121 thoracic track trainees, 118 (97.5%) performed robotic surgery as part of their practice, whereas 62 of 110 (56.4%) cardiothoracic track and 16 of 158 (10.1%) cardiac track trainees performed robotic surgery. In a multivariate analysis, the adoption of robotic surgery was associated with having an established robotic training curriculum (odds ratio, 5.82; 95% CI, 1.32-35.7) and a larger training program (odds ratio, 3.78; 95% CI, 1.34-10.6).

CONCLUSIONS

A disparity exists in robotic surgical training among the training programs. A standardized curriculum and formal case requirements may be needed to ensure optimal preparation for future graduates.

Training and education of operating room nurses in robot-assisted surgery: a systematic review

BACKGROUND

With the introduction of robot-assisted surgery, the role and responsibility of the operating room nurses have been expanded. The surgical team for robotic-assisted surgery depends on the ability of the operating room nurses to operate and handle the robotic system before, during, and after procedures. However, operating room nurses must acquire the necessary competencies for robotic-assisted surgery.

METHOD

We performed a systematic review using the databases MEDLINE and EMBASE to review the evidence on educating and training operating room nurses in robot-assisted surgery. Studies describing operating room nurses' training and team-training with operating room nurses for robot-assisted surgery were included. The Medical Education Research Study Quality Instrument (MERSQI) and the Newcastle-Ottawa Scale-Education (NOS-E) were used to evaluate the quality of the included studies.

RESULTS

We identified 3351 potential studies and included 16 in the final synthesis. Nine studies focused on team-training in robot-assisted surgery: four focused solely on training for operating room nurses, and only three on operating room nurses as first assistants in robot-assisted surgery. Most studies examined team-training in RAS, including OR nurses, focused on emergency situations and conversion to an open procedure. Only a few studies addressed other competencies relevant to OR nurses in RAS. No randomized controlled trials were identified. Only a few studies used pre- and post-testing, and only one examined clinical outcomes. The quality assessment of the included studies was moderate to low, with a median MERSQI score of 10.3 and a median NOS-E score of 2.

CONCLUSION

There is sparse research on the education of operating room nurses in robot-assisted surgery, and the literature emphasizes the training of surgeons. More research is needed to develop evidence-based training for operating room nurses in robot-assisted surgery.

IMRA/SRS Delphi consensus on international standards for common core components of robotic surgical training design

Robotic surgery has expanded internationally at pace. There are multiple local robotic training pathways but there is inconsistency in standardisation of core common components for curricula internationally. A framework is required to define key objectives that can be implemented across robotic training ecosystems. This Delphi consensus aimed to provide recommendations for core considerations in robotic training design across diverse training environments internationally. A literature search was performed and an international steering committee (AG, KL, JW, HM, TC) proposed key components for contemporary robotic training design and a modified Delphi approach was used to gather stakeholder opinion. The outcomes were then discussed at a face-to-face international expert consensus at the IMRA educational session at the Society of Robotic Surgery (SRS) meeting and final voting was conducted on outstanding items. Stakeholders included robotic surgeons, proctors, trainees and robotic surgical training providers. There was consensus achieved in 139 statements organised into 15 themes. There was 100% agreement that standardised themes in robotic curricula may improve patient safety. Key take-home messages include-training curricula should be multiplatform, non-technical skills are an important component of a robotic curriculum as well as console and bedside skills, clinically relevant performance metrics should be used for assessment where available, the reliance on cadaveric and live animal models should be reduced as high-fidelity synthetic models emerge, and stepwise component training is useful for advanced procedural training. These consensus recommendations are intended to guide design of fit for purpose contemporary robotic surgical curricula. Integration of these components into robotic training pathways internationally is recommended.

Simulation-based training in robotic surgery education: bibliometric analysis and visualization

Simulation-based robotic surgery training may help surgeons gain operative skills and experience in the simulation environment. This bibliometric analysis examined the development of simulation-based training for robotic surgical education. Articles pertaining to robotic surgical simulation training that were included in the Web of Science Core Collection up to April 25, 2024, were included. The temporal patterns in published paper numbers were evaluated using Microsoft Excel software, and the data regarding co-authorship and keyword co-occurrence were analyzed and visualized using the VOSviewer and SCImago Graphica tools. A total of 594 papers on simulation-based training for robotic surgical education were evaluated in this study. The United States and United Kingdom were the leading contributors in this field. The most published authors were Professor Ahmed Kamran (23 publications) and Prokar Dasgupta (22 publications). The highest number of papers was published in the journal titled "Surgical Endoscopy and Other Interventional Techniques." The most common keywords were "virtual reality," "curriculum," "robotic surgery simulator," "assessment," and "learning curve." Our study offers a detailed overview of international research on simulation-based training for robotic surgical education, including the publishing countries, institutions, authors, journals, and research hotspots. It also methodically summarizes the state of knowledge in the area, and provides definite directions and concepts for further in-depth analysis.

Development and evaluation of a societal core robotic surgery accreditation curriculum for the UK

Standardised proficiency-based progression is the cornerstone of safe robotic skills acquisition, however, is currently lacking within surgical training curricula. Expert consensuses have defined a modular pathway to accredit surgeons. This study aimed to address the lack of a formal, pre-clinical core robotic skills, proficiency-based accreditation curriculum in the UK. Novice robotic participants underwent a four-day pre-clinical core robotic skills curriculum incorporating multimodal assessment. Modifiable-Global Evaluative Assessment of Robotic Skills (M-GEARS), VR-automated performance metrics (APMs) and Objective Clinical Human Reliability Analysis (OCHRA) error methodology assessed performance at the beginning and end of training. Messick's validity concept and a curriculum evaluation model were utilised. Feedback was collated. Proficiency-based progression, benchmarking, tool validity and reliability was assessed through comparative and correlational statistical methods. Forty-seven participants were recruited. Objective assessment of VR and dry models across M-GEARS, APMs and OCHRA demonstrated significant improvements in technical skill (p < 0.001). Concurrent validity between assessment tools demonstrated strong correlation in dry and VR tasks (r = 0.64-0.92, p < 0.001). OCHRA Inter-rater reliability was excellent (r = 0.93, p < 0.001 and 81% matched error events). A benchmark was established with M-GEARS and for the curriculum at 80%. Thirty (63.82%) participants passed. Feedback was 5/5 stars on average, with 100% recommendation. Curriculum evaluation fulfilled all five domains of Messick's validity. Core robotic surgical skills training can be objectively evaluated and benchmarked to provide accreditation in basic robotic skills. A strategy is necessary to enrol standardised curricula into national surgical training at an early stage to ensure patient safety.

Robotic colorectal surgery training: Portsmouth perspective

This study aims to discuss the principles and pillars of robotic colorectal surgery training and share the training pathway at Portsmouth Hospitals University NHS Trust. A narrative review is presented to discuss all the relevant and critical steps in robotic surgical training. Robotic training requires a stepwise approach, including theoretical knowledge, case observation, simulation, dry lab, wet lab, tutored programs, proctoring (in person or telementoring), procedure-specific training, and follow-up. Portsmouth Colorectal has an established robotic training model with a safe stepwise approach that has been demonstrated through perioperative and oncological results. Robotic surgery training should enable a trainee to use the robotic platform safely and effectively, minimize errors, and enhance performance with improved outcomes. Portsmouth Colorectal has provided such a stepwise training program since 2015 and continues to promote and augment safe robotic training in its field. Safe and efficient training programs are essential to upholding the optimal standard of care.

The Role of Robotics in Meeting Institutional Goals: A Unified Strategy to Facilitate Program Excellence

PURPOSE

The rapid expansion of robotic surgical equipment necessitates a review of the needs and challenges faced by hospitals introducing robots for the first time to compete with experienced institutions. The aim of this study was to analyze the impact of robotic surgery on our hospital compared to open and laparoscopic surgery, examine internal transformations, and assess regional, domestic, and international implications.

METHODS

A retrospective review was conducted of electronic medical records (EMRs) from 2019 to 2022 at Inha University Hospital, including patients who underwent common robotic procedures and equivalent open and laparoscopic operations. The study investigated clinical and operational performance changes in the hospital after the introduction of robotic technology. It also evaluated the operational effectiveness of robot implementation in local, national, and international contexts. To facilitate comparison with other hospitals, the data were transmitted to Intuitive Surgical, Inc. for analysis. The study was conducted in compliance with domestic personal information regulations and received approval from our Institutional Review Board.

RESULTS

We analyzed EMR data from 3,147 patients who underwent surgical treatment. Over a period of 3.5 years, the adoption of robotic technology in a hospital setting significantly enhanced the technical skills of all professors involved. The introduction of robotic systems led to increased patient utilization of conventional surgical techniques, as well as a rise in the number of patients choosing robotic surgery. This collective trend contributed to an overall increase in patient numbers. This favorable evaluation of the operational effectiveness of our hospital's robot implementation in the context of local, national, and global factors is expected to positively influence policy changes.

CONCLUSION

Stakeholders should embrace data science and evidence-based techniques to generate valuable insights from objective data, assess the health of robot-assisted surgery programs, and identify opportunities for improvement and excellence.

Fostering interdisciplinary colorectal and gynaecology surgery networks during training is crucial to maximise expertise and innovate patient care

The importance of interdisciplinary collaboration between specialties has gained significant recognition in recent years, and rightly so with notable benefits to skills acquisition and patient outcomes. Due to the scope of overlapping procedures and clinical scenarios, developing trustable networks between colorectal and gynaecology surgeons must be encouraged as a focus of trainee education. This article highlights the benefits, challenges, and recommendations for fostering such networks.

European Robotic Surgery Consensus (ERSC): Protocol for the development of a consensus in robotic training for gastrointestinal surgery trainees

BACKGROUND

The rapid adoption of robotic surgical systems across Europe has led to a critical gap in training and credentialing for gastrointestinal (GI) surgeons. Currently, there is no existing standardised curriculum to guide robotic training, assessment and certification for GI trainees. This manuscript describes the protocol to achieve a pan-European consensus on the essential components of a comprehensive training programme for GI robotic surgery through a five-stage process.

METHODS AND ANALYSIS

In Stage 1, a Steering Committee, consisting of international experts, trainees and educationalists, has been established to lead and coordinate the consensus development process. In Stage 2, a systematic review of existing multi-specialty robotic training curricula will be performed to inform the formulation of key position statements. In Stage 3, a comprehensive survey will be disseminated across Europe to capture the current state of robotic training and identify potential challenges and opportunities for improvement. In Stage 4, an international panel of GI surgeons, trainees, and robotic theatre staff will participate in a three-round Delphi process, seeking ≥ 70% agreement on crucial aspects of the training curriculum. Industry and patient representatives will be involved as external advisors throughout this process. In Stage 5, the robotic training curriculum for GI trainees will be finalised in a dedicated consensus meeting, culminating in the production of an Explanation and Elaboration (E&E) document.

REGISTRATION DETAILS

The study protocol has been registered on the Open Science Framework (https://osf.io/br87d/).

Development and validation of metrics for a new RAPN training model

Robot-assisted partial nephrectomy (RAPN) is a complex and index procedure that urologists need to learn how to perform safely. No validated performance metrics specifically developed for a RAPN training model (TM) exist. A Core Metrics Group specifically adapted human RAPN metrics to be used in a newly developed RAPN TM, explicitly defining phases, steps, errors, and critical errors. A modified Delphi meeting concurred on the face and content validation of the new metrics. One hundred percent consensus was achieved by the Delphi panel on 8 Phases, 32 Steps, 136 Errors and 64 Critical Errors. Two trained assessors evaluated recorded video performances of novice and expert RAPN surgeons executing an emulated RAPN in the newly developed TM. There were no differences in procedure Steps completed by the two groups. Experienced RAPN surgeons made 34% fewer Total Errors than the Novice group. Performance score for both groups was divided at the median score using Total Error scores, into HiError and LoError subgroups. The LowErrs Expert RAPN surgeons group made 118% fewer Total Errors than the Novice HiErrs group. Furthermore, the LowErrs Expert RAPN surgeons made 77% fewer Total Errors than the HiErrs Expert RAPN surgeons. These results established construct and discriminative validity of the metrics. The authors described a novel RAPN TM and its associated performance metrics with evidence supporting their face, content, construct, and discriminative validation. This report and evidence support the implementation of a simulation-based proficiency-based progression (PBP) training program for RAPN.

The deconstructed procedural description in robotic colorectal surgery

Increasing robotic surgical utilisation in colorectal surgery internationally has strengthened the need for standardised training. Deconstructed procedural descriptions identify components of an operation that can be integrated into proficiency-based progression training. This approach allows both access to skill level appropriate training opportunities and objective and comparable assessment. Robotic colorectal surgery has graded difficulty of operative procedures lending itself ideally to component training. Developing deconstructed procedural descriptions may assist in the structure and progression components in robotic colorectal surgical training. There is no currently published guide to procedural descriptions in robotic colorectal surgical or assessment of their training utility. This scoping review was conducted in June 2022 following the PRISMA-ScR guidelines to identify which robotic colorectal surgical procedures have available component-based procedural descriptions. Secondary aims were identifying the method of development of these descriptions and how they have been adapted in a training context. 20 published procedural descriptions were identified covering 8 robotic colorectal surgical procedures with anterior resection the most frequently described procedure. Five publications included descriptions of how the procedural description has been utilised for education and training. From these publications terminology relating to using deconstructed procedural descriptions in robotic colorectal surgical training is proposed. Development of deconstructed robotic colorectal procedural descriptions (DPDs) in an international context may assist in the development of a global curriculum of component operating competencies supported by objective metrics. This will allow for standardisation of robotic colorectal surgical training and supports a proficiency-based training approach.

Human Factors Integration in Robotic Surgery

OBJECTIVE

Using the example of robotic-assisted surgery (RAS), we explore the methodological and practical challenges of technology integration in surgery, provide examples of evidence-based improvements, and discuss the importance of systems engineering and clinical human factors research and practice.

BACKGROUND

New operating room technologies offer potential benefits for patients and staff, yet also present challenges for physical, procedural, team, and organizational integration. Historically, RAS implementation has focused on establishing the technical skills of the surgeon on the console, and has not systematically addressed the new skills required for other team members, the use of the workspace, or the organizational changes.

RESULTS

Human factors studies of robotic surgery have demonstrated not just the effects of these hidden complexities on people, teams, processes, and proximal outcomes, but also have been able to analyze and explain in detail why they happen and offer methods to address them. We review studies on workload, communication, workflow, workspace, and coordination in robotic surgery, and then discuss the potential for improvement that these studies suggest within the wider healthcare system.

CONCLUSION

There is a growing need to understand and develop approaches to safety and quality improvement through human-systems integration at the frontline of care.Precis: The introduction of robotic surgery has exposed under-acknowledged complexities of introducing complex technology into operating rooms. We explore the methodological and practical challenges, provide examples of evidence-based improvements, and discuss the implications for systems engineering and clinical human factors research and practice.

Identifying barriers to resident robotic console time in a general surgery residency through a targeted needs assessment

Robotic-assisted general surgery is experiencing exponential growth. Despite our institution's high volume, residents often graduate with inadequate console experience. Our aim was to identify the educational needs of residents and perceived barriers to residents' console time from both attendings and residents. Separate surveys were created and distributed to robotic surgery faculty and general surgery residents at our institution. Questions were a variety of modalities and focused on the robotic surgery experience at our institution, including barriers to resident console time from both attending surgeon and resident perspectives. Although residents' interest in robotic surgery exceeded that of open and laparoscopic surgery, confidence in their robotic skills was low compared to the other modalities. The top barriers to participating in robotic cases according to residents included minimal or no previous console time with the attending, lack of simulator time, and being required to perform bedside assistant duties. Faculty reported resident preparedness, prior robotic skill demonstration, simulator time, case complexity, and their own confidence as significant factors influencing resident console time. Using these results, we concluded that the design and implementation of a formal robotic surgery curriculum should incorporate simulation-based opportunities for residents to practice their skills, improve confidence, and increase console experience. In addition, simulation opportunities for faculty should also be considered to allow for improvement and maintenance of robotic surgical skills.

Transfer of acquired practical skills from dry lab into live surgery using the avatera robotic system: An experimental study

OBJECTIVE

To evaluate the transfer of the practical skills of robot-assisted surgery acquired in the dry-lab into a real live experimental setting for performing upper and lower urinary tract surgeries.

MATERIAL AND METHODS

An in vivo experimental study design was utilized. Six urology trainees and fellows; two 2nd year trainees with no previous exposure to laparoscopic surgery (Group 1), two 4th year residents with medium exposure to laparoscopic surgery (Group 2) and two fellows trained to perform laparoscopic surgeries (Group 3) performed ureteral reimplantation into the bladder, pyeloplasty, and radical nephrectomy on three female pigs under general anesthesia. Prior to performing the requested procedures, each participant completed 10-14 h dry-lab robotic training acquiring skills in basic surgical tasks, such as suturing, cutting and needle passage. The recorded variables were the successful completion of the procedures, the console time, and the time to perform different steps and major complications.

RESULTS

All procedures were completed successfully by all groups except the pyeloplasty by group 1 which was complicated by bleeding from the renal vein, and the procedure was abandoned. Group 3 achieved shorter console time for all successfully completed procedures and for separate surgical steps compared to all groups, followed by Group 2. The slowest group for all procedures and steps analyzed was Group 3.

CONCLUSIONS

Although further clinical evidence is needed, the robotic-assisted urological procedures and the most challenging steps could be performed safely and effectively after proper training in the dry lab under mentor supervision according to our study.

Validation of a multidisciplinary virtual reality (VR) robotic surgical curriculum

The objective is to identify whether trainees demonstrate improvement in a standardized knot-tying task as assessed by Global Evaluative Assessment of Robotic Skills (GEARS) score after completion of a virtual reality (VR) robotic curriculum. An IRB-exempt prospective study was conducted with surgical trainees from August 2021 to February 2023. Participants initially performed a baseline robotic suturing task in which they were instructed to tie interrupted square knots in 10 min. Participants then completed a virtual reality simulation curriculum involving 23 exercises until they achieved 90% proficiency on all tasks. Participants then repeated the suturing task. Pre- and post-curriculum suturing tasks were recorded, de-identified, and scored by expert graders using a GEARS score. Trainees from three academic centers were invited to participate. Medical students (MS1-MS3) and surgical residents from gynecology, urology, and general surgery were invited to participate. Twenty-five trainees completed the pre-curriculum suturing task, the VR curriculum, and the post-curriculum suturing task. Trainees demonstrated significant improvement in their post-test GEARS score by 2.43 points (p < 0.05) and were able to tie three additional knots within 10 min after completion of the curriculum (p < 0.05). Trainees also demonstrated a faster time to complete first knot (114 s improvement, p < 0.05) after completion of the curriculum. All participants agreed or strongly agreed that completion of the robotic curriculum helped them feel more comfortable using the robotic console, and improved their robotic surgical skills. Surgical trainees and medical students with limited prior robotic surgical experience demonstrated objective improvement after completion of a standardized VR curriculum.

Current practises and the future of robotic surgical training

INTRODUCTION

This study reviews the current state of robotic surgery training for surgeons, including the various curricula, training methods, and tools available, as well as the challenges and limitations of these.

METHODS

The authors carried out a literature search across PubMed, MEDLINE, and Google Scholar using keywords related to 'robotic surgery', 'computer-assisted surgery', 'simulation', 'virtual reality', 'surgical training', and 'surgical education'. Full text analysis was performed on 112 articles.

TRAINING PROGRAMMES

The training program for robotic surgery should focus on proficiency, deliberation, and distribution principles. The curricula can be broadly split up into pre-console and console-side training. Pre-Console and Console-Side Training: Simulation training is an important aspect of robotic surgery training to improve technical skill acquisition and reduce mental workload, which helps prepare trainees for live procedures.

OPERATIVE PERFORMANCE ASSESSMENT

The study also discusses the various validated assessment tools used for operative performance assessments.

FUTURE ADVANCES

Finally, the authors propose potential future directions for robotic surgery training, including the use of emerging technologies such as AI and machine learning for real-time feedback, remote mentoring, and augmented reality platforms like Proximie to reduce costs and overcome geographic limitations.

CONCLUSION

Standardisation in trainee performance assessment is needed. Each of the robotic curricula and platforms has strengths and weaknesses. The ERUS Robotic Curriculum represents an evidence-based example of how to implement training from novice to expert. Remote mentoring and augmented reality platforms can overcome the challenges of high equipment costs and limited access to experts. Emerging technologies offer promising advancements for real-time feedback and immersive training environments, improving patient outcomes.

Pain Education and Knowledge (PEAK) Consensus Guidelines for Neuromodulation: A Proposal for Standardization in Fellowship and Training Programs

The need to be competent in neuromodulation is and should be a prerequisite prior to completing a fellowship in interventional pain medicine. Unfortunately, many programs lack acceptable candidates for these advanced therapies, and fellows may not receive adequate exposure to neuromodulation procedures. The American Society of Pain and Neuroscience (ASPN) desires to create a consensus of experts to set a minimum standard of competence for neurostimulation procedures, including spinal cord stimulation (SCS), dorsal root ganglion stimulation (DRG-S), and peripheral nerve stimulation (PNS). The executive board of ASPN accepted nominations for colleagues with excellence in the subject matter of neuromodulation and physician education. This diverse group used peer-reviewed literature and, based on grading of evidence and expert opinion, developed critical consensus guides for training that all accredited fellowship programs should adopt. For each consensus point, transparency and recusal were used to eliminate bias, and an author was nominated for evidence grading oversight and bias control. Pain Education and Knowledge (PEAK) Consensus Guidelines for Neuromodulation sets a standard for neuromodulation training in pain fellowship training programs. The consensus panel has determined several recommendations to improve care in the United States for patients undergoing neuromodulation. As neuromodulation training in the United States has evolved dramatically, these therapies have become ubiquitous in pain medicine. Unfortunately, fellowship programs and the Accreditation Council for Graduate Medical Education (ACGME) pain program requirements have not progressed training to match the demands of modern advancements. PEAK sets a new standard for fellowship training and presents thirteen practice areas vital for physician competence in neuromodulation.

What credentials are required for robotic-assisted surgery in reconstructive and functional urology?

Introduction

The increasing popularity of robotic assisted surgery (RAS) as it is implemented in to sub specialities poses many challenges to ensuring standards in quality and safety. The area of Reconstructive and Functional Urology (RFU) has a wide range and largely complex heterogeneous procedures. In recent years RFU has started to incorporate RAS as the primary method to undertake these procedures due to improved vision, dexterity, and access to deep cavities. To ensure patient safety majority of institutions maintain minimal requirements to operate using RAS however across specialities and institutions these greatly vary.

Methods

A narrative review of all the relevant papers known to the author was conducted.

Results

Specific challenges facing RFU is the inability to rely on case numbers as a surrogate means to measure competency as well the ongoing consideration of how to differentiate between surgeons with robotic training and those with the clinical experience specific to RFU.

Conclusion

This review explores current models of training and credentialling and assess how it can be adapted to suggest a standardised guideline for RFU to ensure the highest standards of patient care.

Utilising an accelerated Delphi process to develop consensus on the requirement and components of a pre-procedural core robotic surgery curriculum

Robot-assisted surgery (RAS) continues to grow globally. Despite this, in the UK and Ireland, it is estimated that over 70% of surgical trainees across all specialities have no access to robot-assisted surgical training (RAST). This study aimed to provide educational stakeholders guidance on a pre-procedural core robotic surgery curriculum (PPCRC) from the perspective of the end user; the surgical trainee. The study was conducted in four Phases: P1: a steering group was formed to review current literature and summarise the evidence, P2: Pan-Specialty Trainee Panel Virtual Classroom Discussion, P3: Accelerated Delphi Process and P4: Formulation of Recommendations. Forty-three surgeons in training representing all surgical specialties and training levels contributed to the three round Delphi process. Additions to the second- and third-round surveys were formulated based on the answers and comments from previous rounds. Consensus opinion was defined as ≥ 80% agreement. There was 100% response from all three rounds. The resulting formulated guidance showed good internal consistency, with a Cronbach alpha of > 0.8. There was 97.7% agreement that a standardised PPCRC would be advantageous to training and that, independent of speciality, there should be a common approach (95.5% agreement). Consensus was reached in multiple areas: 1. Experience and Exposure, 2. Access and context, 3. Curriculum Components, 4 Target Groups and Delivery, 5. Objective Metrics, Benchmarking and Assessment. Using the Delphi methodology, we achieved multispecialty consensus among trainees to develop and reach content validation for the requirements and components of a PPCRC. This guidance will benefit from further validation following implementation.

[Status quo of urological residency training in Germany-a strengths, weaknesses, opportunities, and threats (SWOT) analysis]

BACKGROUND

Urological residency training is a decisive step on the urological career path. The aim of this review is to develop strategies and approaches to actively shape, improve and further develop urological residency training.

METHODS

With the help of a strengths, weaknesses, opportunities, and threats (SWOT) analysis, the status quo of urological residency training in Germany is analyzed in a structured manner.

RESULTS

Strengths of urological residency training incorporate the attractiveness of the specialty itself, and the residency training curriculum in urology ("Weiterbildungscurriculum Urologie", WECU), including the networking of inpatient and outpatient training and accompanying internal and external further training. The German Society of Residents in Urology (GeSRU) also provides a networking platform for residents. Weaknesses include country-specific differences and a lack of checkpoints during residency training. Opportunities for urological continuing education arise from freelance work, digitalization, and technical and medical progress. In contrast, the aftermath of the coronavirus disease 2019 (COVID 19) pandemic, with still limited staff and surgical capacities, an increased psychosocial workload, and the rising number of outpatient treatments in urology pose threats for urological residency programs.

CONCLUSIONS

With the help of a SWOT analysis, factors for the further development of urological residency training can be identified. In order to provide high-quality residency training in the future, strengths and opportunities should be consolidated and weaknesses and threats should be addressed at an early stage.

A Multi-Institutional Needs Assessment in the Development of a Robotic Surgery Curriculum: Perceptions From Resident and Faculty Surgeons

BACKGROUND

The growing adoption of robotic-assisted surgery mandates residents must acquire robotic skills. No standardized curriculum for robotic surgery exists. Therefore, programs have developed their own curricula, which are often unstructured and based on resource availability. With this strategy programs may not adhere to scholarly approaches in curriculum development. We aimed to obtain a multi-institutional needs assessment to address training needs and identify integral components of a formalized robotic surgery curriculum.

METHODS

A 10-question survey was distributed to general surgery residents. A separate 7-question survey was sent to robotic faculty surgeons at 3 institutions. Survey questions queried demographics, opinions regarding robotic training, proficiency definitions, and identification of procedures and instructional strategies for a curriculum. Mann- Whitney U test and Fisher's exact test were performed to compare responses amongst residents and faculty. Spearman's correlation was used to identify relationships between experience or post-graduate year (PGY) with response selection.

RESULTS

Both residents and faculty believed robotic training should start in the PGY1 (55.1% vs 52%; p = 0.58). Faculty recognized robotic training to be more important compared to residents (84% vs 58.1%; p < 0.05). Both groups considered a minimum of 21 to 40 robotic cases to be sufficient exposure during training (p = 0.30). Cholecystectomy (82.4% vs 72%; p = 0.261), ventral hernia repair (89.2% vs 88%; p = 1.0), inguinal hernia repair (91.9% vs 92%; p = 1.0), and right colectomy (83.8% vs 80%; p = 0.7) were considered to be the most appropriate robotic procedures during training. Both groups concurred that bedside (91.9% vs 100%; p = 0.33) and console skills training (97.3% vs 100%; p = 1.0), small group simulation (94.6% vs 72% p = 0.005), and independent practice (87.8% vs 92% p = 0.73), were instructional strategies vital to a curriculum. Faculty considered online didactic modules (96% vs 59.5%; p < 0.05) to be more important, whereas residents favored small group experiences for fundamental skills (94.6% vs. 72%; p < 0.05) and procedure-based simulation (96% vs 64%; p < 0.05).

CONCLUSIONS

Our targeted needs assessment identified requisite components of a robotics curriculum, which are feasible and accepted by both residents and faculty. Medical educators can use this as a resource to develop a formal robotics training curriculum.

Identifying curriculum content for operating room nurses involved in robotic-assisted surgery: a Delphi study

BACKGROUND

Currently, no generally accepted curriculum for operating room nurses (OR nurses) working with robotic-assisted surgery (RAS) exists. OR nurses working with RAS require different competencies than regular OR nurses, e.g. knowledge of the robotic system and equipment and specific emergency undocking procedures. The objective of this study was to identify learning goals for a curriculum for OR nurses working with RAS and to investigate which learning methods should be used.

METHODS

A three-round Delphi approach, with an additional survey, was used in this study. Four OR nurses from every department in gynecology, urology, and surgical gastroenterology doing RAS in Denmark were invited to participate.

RESULTS

The response rates were 93%, 81%, and 79%, respectively, in the three rounds of the Delphi survey and 68% in the additional survey. After the processing of data, a list of 57 learning goals, sorted under 11 domains, was produced. 41 learning goals were rated Relevant, Very relevant, or Essential spread over 10 of the 11 domains. The top 3 learning goals rated as Essential: Identify the most common injuries related to patient positioning during robotic-assisted surgery and know how to avoid them, Connect, calibrate and handle the scope, Perform an emergency undocking procedure. The panel rated Supervised training during surgery on patients as the most relevant learning method, followed by Dry lab and Team training.

CONCLUSIONS

The learning goals identified in this study, can be used as the basis for a curriculum for OR nurses working with RAS. During the processing, it became clear that there is a need to further investigate issues such as communication challenges, awareness of emergency procedures, and differences in the skills required depending on the role of the RAS nurse.

Standardized evaluation of satisfaction within urology residents during clinical training: Implementation of a new urological residency rotation program at the university hospital Frankfurt

Background

Structured curricula are demanded to improve training programs of future urologists. This study aimed to evaluate the acceptance of the newly implemented residency rotation program at the University Hospital Frankfurt. Primary endpoint was resident's satisfaction with the current residency rotation program. Secondary endpoint was the fulfilment of the objectives and expectations by residents.

Methods

A standardized 15-item, online-based survey was sent to every urologic resident of the University Hospital Frankfurt, completing their rotation between August 2020 and August 2022. In addition to baseline characteristics, training and working conditions were assessed. Descriptive statistics were applied.

Results

In total 15 rotations of the Residency Rotation Program at the University Hospital Frankfurt were evaluated, including urologic practice (5/15), Intermediate Care Unit (4/15), urooncology (4/15) and clinical exchange to St. Gallen (2/15). Overall, the majority were very (67%) or rather satisfied (2%) with their rotation. Of the pre-rotation defined objectives, 71% were fulfilled, 18% partially fulfilled and 8% not fulfilled. With respect to the expectations, 67% were fulfilled, 19% partly fulfilled and 4% were not fulfilled. All residents would recommend their respective rotations.

Conclusion

Our results demonstrate that the residency rotation program at the University Hospital Frankfurt enjoys a high level of acceptance as well as a positive impact on urologic training. Satisfaction with the completed rotation was convincing, most of the expectations and objectives for the respective rotation could be fulfilled. These results help to ensure the quality of urologic curricula and to improve the structure of training programs for future urologists.

Multidisciplinary perceptions on robotic surgical training: the robot is a stimulus for surgical education change

BACKGROUND

It is unclear how to best establish successful robotic training programs or if subspecialty robotic program principles can be adapted for general surgery practice. The objective of this study is to understand the perspectives of high-volume robotic surgical educators on best practices in robotic surgery training and to provide recommendations transferable across surgical disciplines.

METHODS

This multi-institutional qualitative analysis involved semi-structured interviews with high-volume robotic educators from academic general surgery (AGS), community general surgery (CGS), urology (URO), and gynecology (GYN). Purposeful sampling and snowballing ensured high-volume status and geographically balanced representation across four strata. Interviews were transcribed, deidentified, and independently, inductively coded. A codebook was developed and refined using constant comparative method until interrater reliability kappa reached 0.95. A qualitative thematic, framework analysis was completed.

RESULTS

Thirty-four interviews were completed: AGS (n = 9), CGS (n = 8), URO (n = 9), and GYN (n = 8) resulting in 40 codes and four themes. Theme 1: intangibles of culture, resident engagement, and faculty and administrative buy-in are as important as tangibles of robot and simulator access, online modules, and case volumes. Theme 2: robotic OR integration stresses the trainee-autonomy versus patient-safety balance. Theme 3: trainees acquire robotic skills along individual learning curves; benchmark assessments track progress. Theme 4: AGS can learn from URO and GYN through multidisciplinary collaboration but must balance pre-existing training program use with context-specific curricular needs.

CONCLUSIONS

Robotic surgical experts emphasize the importance of universal training paradigms, such as a strong educational culture that balances autonomy and patient safety, collaboration between disciplines, and routine assessments for continuous growth. Often, introduction and acceptance of the robot serves as a stimulus to discuss broader surgical education change.

[Promotion of next generation urologists-Construct urology of the future]

In view of the growing demand for urological care and the simultaneous demographic change, the need for urologists in Germany is increasing. Therefore, young professionals are urgently needed to ensure urological care in the future. This objective can be achieved by fascinating medical students for urology and by implementing satisfactory residency programs in clinical departments and outpatient offices. Perspectives and possible career paths should be shown to junior colleagues at an early stage. Structured research funding is needed to reconcile academic with clinical work. The German Society for Residents in Urology (GeSRU) offers young urologists a platform for networking, for representation of interests as well as for education and training.

Robotic Kidney Transplant: The Modern Era Technical Revolution

Since the mid 20th century, transplantation has been a fast-developing field of contemporary medicine. The technical aspects of transplant operations were developed in the 1950s, with little significant change for >50 y. Those techniques allowed completion of various organ transplants and successful patient outcomes, but they also carried the inherent disadvantages of open surgery, such as postoperative pain, wound complications and infections, and prolonged length of hospital stay. The introduction and adoption of minimally invasive surgical techniques in the early 1990s to various surgical specialties including general, gynecologic, and urologic surgery led to significant improvements in postoperative patient care and outcomes. Organ transplantation, with its precision demanding vascular anastomoses, initially had been considered infeasible to accomplish with conventional laparoscopic devices. The institution of robotic surgical technology in the late 1990s and its subsequent wide utilization in fields of surgery changed its accessibility and acceptance. With the steady camera, 3D views, and multidirectional wrist motions, surgical robotics opened new horizons for technically demanding surgeries such as transplantation to be completed in a minimally invasive fashion. Furthermore, the hope was this technique could find a niche to treat patients who otherwise are not deemed surgical candidates in many fields including transplantation. Here in, robotics in kidney transplantation and its ability to help provide equity through access to transplantation will be discussed.

A multi-surgeon learning curve analysis of overall and site-specific positive surgical margins after RARP and implications for training

Robot-assisted radical prostatectomy (RARP) is the most adopted treatment for localized prostate cancer. The aim of this study was to explore the learning curves (LC) for overall and site-specific positive surgical margins (PSM) occurrence after RARP of multiple surgeons within a step-structured mentor-initiated training program. The study included consecutive patients undergoing RARP between January 2013 and March 2020, by three surgeons: a mentor and his two trainees. Prospectively collected patients' data were retrospectively analyzed. The cumulative summation (CUSUM) method was used to generate the LCs, with turning points indicating the number of cases to reach proficiency levels. Furthermore, the association between PSM and surgical experience was evaluated, adjusting for case mix. A total of 761 consecutive patients were included, 370 treated by the Mentor surgeon, 247 and 144 treated, respectively, by the two Trainees. Mentor and Trainees had similar PSM rates (31.6% vs 28.0% vs 31.3%, p = 0.6). CUSUM charts showed different LC shapes for different PSM locations (postero-lateral, bladder neck, apex, and multifocal/> 3 mm). Surgical experience was significantly associated with overall, postero-lateral, and multifocal/> 3 mm PSMs, in the Mentor series only. Trainees reached their turning points after far fewer cases then the Mentor, both for overall (12 and 31 vs 153), postero-lateral (24 and 30 vs 120), and multifocal/> 3 mm PSMs (9 and 31 vs 153). The achievement of stable SM proficiency takes involved different LCs depending on the prostatic location being considered. Monitoring site-specific LC can indicate the surgical steps for which there may be still room for further technical refinements, even when an apparent proficiency status seems achieved.

Role and Training of the Bedside Surgeon in Robotic Surgery: A Survey Among French Urologists-in-Training

Introduction

Due to the development of robotic surgery, surgeons operating at the console are physically separated from the patient. They must rely on help from an assistant, also called bedside surgeon. This study aimed to investigate the habits and practices of French urologic residents when performing this role and to determine whether they expected specific training to qualify as bedside surgeons.

Materials and Methods

A web-based survey was sent to French urology residents and fellows using the mailing-list of the French Association of Urologists in Training (AFUF).

Results

Over a 3-month period, 86 residents and fellows responded to the survey. Seventy-five (87.2%) thought that an experience as bedside surgeon was useful to acquire console surgeon status and, more specifically, 48.2% of them indicated that this former experience was vital. Nearly 64% considered that learning robotic surgery was essential during residency and fellowship. Overall, 91.9% believed that bedside surgeons should receive a formal training. They were 69.7% to need 5 to 10 procedures to feel confident as bedside surgeon. Almost 75% underwent laparoscopic training on simulators. Having access to a surgery school significantly increased the probability of receiving laparoscopic training on simulators (p = 0.0033).

Conclusion

French urology residents and fellows expect a specific training program for bedside surgeons to increase their level of confidence and to get familiar with the device during their first robotic procedures. For them, a bedside surgeon program on a regional/national level would be required.

A review of robotic surgical training: establishing a curriculum and credentialing process in ophthalmology

Ophthalmic surgery requires a highly dexterous and precise surgical approach to work within the small confines of the eye, and the use of robotics offers numerous potential advantages to current surgical techniques. However, there is a lag in the development of a comprehensive training and credentialing system for robotic eye surgery, and certification of robotic skills proficiency relies heavily on industry leadership. We conducted a literature review on the curricular elements of established robotics training programs as well as privileging guidelines from various institutions to outline key components in training and credentialing robotic surgeons for ophthalmic surgeries. Based on our literature review and informal discussions between the authors and other robotic ophthalmic experts, we recommend that the overall training framework for robotic ophthalmic trainees proceeds in a stepwise, competency-based manner from didactic learning, to simulation exercises, to finally operative experiences. Nontechnical skills such as device troubleshooting and interprofessional teamwork should also be formally taught and evaluated. In addition, we have developed an assessment tool based on validated global rating scales for surgical skills that may be used to monitor the progress of trainees. Finally, we propose a graduating model for granting privileges to robotic surgeons. Further work will need to be undertaken to assess the feasibility, efficacy and integrity of the training curriculum and credentialing practices for robotic ophthalmic surgery.

Identifying curriculum content for a cross-specialty robotic-assisted surgery training program: a Delphi study

BACKGROUND

Robotic-assisted surgery is increasing and there is a need for a structured and evidence-based curriculum to learn basic robotic competencies. Relevant training tasks, eligible trainees, realistic learning goals, and suitable training methods must be identified. We sought to develop a common curriculum that can ensure basic competencies across specialties.

METHODS

Two robotic surgeons from all departments in Denmark conducting robotic-assisted surgery within gynecology, urology, and gastrointestinal surgery, were invited to participate in a three-round Delphi study to identify learning goals and rank them according to relevance for a basic curriculum. An additional survey was conducted after the Delphi rounds on what training methods were considered best for each learning goal and who (console surgeon/patient-side assistant) should master each learning goal.

RESULTS

Fifty-six robotic surgeons participated and the response rates were 86%, 89%, and 77%, for rounds 1, 2 and 3, respectively. The Delphi study identified 40 potential learning goals, of which 29 were ranked as essential, e.g., Understand the link between arm placement and freedom of movement or Be able to perform emergency un-docking. In the additional survey, the response rate was 70%. Twenty-two (55%) of the identified learning goals were found relevant for the patient-side assistant and twenty-four (60%) were linked to a specific suitable learning method with > 75% agreement.

CONCLUSIONS

Our findings can help training centers plan their training programs concerning educational content and methods for training/learning. Furthermore, patient-side assistants should also receive basic skills training in robotic surgery.

From cadaveric and animal studies to the clinical reality of robotic mastectomy: a feasibility report of training program

Robotic nipple-sparing mastectomy (RNSM) provides better cosmetic outcomes and improves the quality of life of women with breast cancer. However, this has not been widely adapted due to the lack of well-structured training programs. The present study aimed to report the establishment of cadaveric and animal skill laboratory training programs for RNSM and the participants’ perception on the training programs. We performed 24 RNSMs using 11 cadavers and one porcine model. Then, the skill laboratory characteristics were reviewed. Five trainers and 10 trainees participated in the programs. The first four cadaveric RNSMs with latissimus dorsi flaps and implants were performed using the da Vinci Si® system. We performed 14 and six RNSMs using the Xi® and SP® systems, respectively. The scores for questionnaires on the satisfaction with the training consisted of the trainees’ perceived goals in attending the course, teaching/learning environment, and teaching staff performance. The scores were excellent. Cadaveric or porcine RNSM skill laboratory training may be essential programs that can provide safe and efficient training.

Improvement of three-dimensional motion sickness using a virtual reality simulator for robot-assisted surgery in undergraduate medical students: A prospective observational study

BACKGROUND

A virtual reality (VR) simulator is utilized as an inexpensive tool for gaining basic technical competence in robotic-assisted surgery (RAS). We evaluated operator 3D motion sickness while using a VR simulator and assessed whether it can be reduced by repeating the training.

METHODS

This prospective observational study was conducted at the Department of Urology, Iwate Medical University, a tertiary training hospital in an urban setting. A total of 30 undergraduate medical students participated in the study. We compared whether the VR simulator improved the students' skills in operating the da Vinci robot. Fifteen students underwent training with a VR simulator for 4 h a day for 5 days. Then, motion sickness was determined using the Visual Analog Scale and Simulator Sickness Questionnaire (SSQ) before and after the training.

RESULTS

Manipulation time significantly improved after training compared to before training (293.9 ± 72.4 versus 143.6 ± 18.4 s; p < 0.001). Although motion sickness worsened after each training session, it gradually improved with continuous practice with the VR simulator. SSQ subscores showed that the VR simulator induced nausea, disorientation, and oculomotor strain, and oculomotor strain was significantly improved with repeated training.

CONCLUSIONS

In undergraduate students, practice with the VR simulator improved RAS skills and operator 3D motion sickness caused by 3D manipulation of the da Vinci robot.

Evolving robotic surgery training and improving patient safety, with the integration of novel technologies

INTRODUCTION

Robot-assisted surgery is becoming increasingly adopted by multiple surgical specialties. There is evidence of inherent risks of utilising new technologies that are unfamiliar early in the learning curve. The development of standardised and validated training programmes is crucial to deliver safe introduction. In this review, we aim to evaluate the current evidence and opportunities to integrate novel technologies into modern digitalised robotic training curricula.

METHODS

A systematic literature review of the current evidence for novel technologies in surgical training was conducted online and relevant publications and information were identified. Evaluation was made on how these technologies could further enable digitalisation of training.

RESULTS

Overall, the quality of available studies was found to be low with current available evidence consisting largely of expert opinion, consensus statements and small qualitative studies. The review identified that there are several novel technologies already being utilised in robotic surgery training. There is also a trend towards standardised validated robotic training curricula. Currently, the majority of the validated curricula do not incorporate novel technologies and training is delivered with more traditional methods that includes centralisation of training services with wet laboratories that have access to cadavers and dedicated training robots.

CONCLUSIONS

Improvements to training standards and understanding performance data have good potential to significantly lower complications in patients. Digitalisation automates data collection and brings data together for analysis. Machine learning has potential to develop automated performance feedback for trainees. Digitalised training aims to build on the current gold standards and to further improve the 'continuum of training' by integrating PBP training, 3D-printed models, telementoring, telemetry and machine learning.

Bioethical implications of robotic surgery in urology: a narrative review

BACKGROUND

Robotic technologies are being increasingly implemented in healthcare, including urology, holding promises for improving medicine worldwide. However, these new approaches raise ethical concerns for professionals, patients, researchers and institutions that need to be addressed. The aim of this review is to investigate the existing literature related to bioethical issues associated with robotic surgery in urology, in order to identify current challenges and make preliminary suggestions to ensure an ethical implementation of these technologies.

METHODS

We performed a narrative review of the pertaining literature through a systematic search of two databases (PubMed and Web of Science) in August 2020.

RESULTS

Our search yielded 76 articles for full-text evaluation and 48 articles were included in the narrative review. Several bioethical issues were identified and can be categorized into five main subjects: 1) robotic surgery accessibility; 2) safety; 3) gender gap; 4) costs and 5) learning curve. 1) Robotic surgery is expensive, and in some health systems may lead to inequality in healthcare access. In more affluent countries the national distribution of several robotic platforms may influence the centralization of robotic surgery, therefore potentially affecting oncological and functional outcomes in low-volume centers. 2) There is a considerable gap between surgical skills and patients' perception of competence, leading to ethical consequences on modern healthcare. Published incidence of adverse events during robotic surgery in large series is between 2% and 15%, which does not significantly differ amongst open or laparoscopic approaches. 3) No data about gap differences in accessibility to robotic platforms were retrieved from our search. 4) Robotic platforms are expensive but a key reason why hospitals are willing to absorb the high upfront costs is patient demand. It is possible to achieve cost-equivalence between open and robotic prostatectomy if the volume of centers is higher than 10 cases per week. 5) A validated, structured curriculum and accreditation has been created for robotic surgery. This allows acquisition and development of basic and complex robotic skills focusing on patient safety and short learning curve.

CONCLUSIONS

Tech-medicine is rapidly moving forward. Robotic approach to urology seems to be accessible in more affluent countries, safe, economically sustainable, and easy to learn with an appropriate learning curve for both sex. It is mandatory to keep maintaining a critical rational approach with constant control of the available evidence regarding efficacy, efficiency and safety.

Early outcomes of robot-assisted radical prostatectomy following completion of a structured training curriculum: a single surgeon cohort study

Objective:

Technical skills in robot-assisted radical prostatectomy (RARP) are not mandated by the Intercollegiate Surgical Curriculum Programme. The European Association of Urology Robotic Urology Section (ERUS) developed a structured curriculum; however, surgeons’ outcomes data from subsequent independent practice are limited. We describe the initial post-ERUS curriculum RARP outcomes for a United Kingdom (UK)-based surgeon.

Patients and methods:

This was a prospective single surgeon cohort study of 272 patients who underwent RARP between February 2016 and October 2019 in a high-volume UK centre and who were followed up at approximately 3 and 12 months. Positive surgical margins (PSMs), and 3- and 12-month continence rates were obtained and used to generate learning curves, with point of plateau estimated from logarithmic trendlines.

Results:

Overall (⩾3 mm) PSM rate for pT2 was 14.9% (5.4%) and pT3 was 22.6% (3.2%). Where data were available, 70.5% (of n=251) and 95.5% (of n=154) patients achieved social continence (0–1 pads) at 3 and 12 months, respectively. PSM and 3-month social continence rates plateaued at ~175 and ~100 cases, respectively.

Conclusion:

Following completion of the ERUS RARP curriculum, early oncological and functional outcomes consistent with published standards are rapidly achievable in independent practice. These data exemplify the potential value of a standardised RARP training curriculum to mitigate possible compromises in outcomes.

Level of evidence:

IV

Comprehensive Learning Curve of Robotic Surgery: Discovery From a Multicenter Prospective Trial of Robotic Gastrectomy

OBJECTIVE

To evaluate the complication-based learning curve and identify learning-associated complications of robotic gastrectomy.

SUMMARY BACKGROUND DATA

With the increased popularity of robotic surgery, a sound understanding of the learning curve in the surgical outcome of robotic surgery has taken on great importance. However, a multicenter prospective study analyzing learning-associated morbidity has never been conducted in robotic gastrectomy.

METHODS

Data on 502 robotic gastrectomy cases were prospectively collected from 5 surgeons. Risk-adjusted cumulative sum analysis was applied to visualize the learning curve of robotic gastrectomy on operation time and complications.

RESULTS

Twenty-five cases, on average, were needed to overcome complications and operation time-learning curve sufficiently to gain proficiency in 3 surgeons. An additional 23 cases were needed to cross the transitional phase to progress from proficiency to mastery. The moderate complication rate (CD ≥ grade II) was 20% in phase 1 (cases 1-25), 10% in phase 2 (cases 26-65), 26.1% in phase 3 (cases 66-88), and 6.4% in phase 4 (cases 89-125) (P < 0.001). Among diverse complications, CD ≥ grade II intra-abdominal bleeding (P < 0.001) and abdominal pain (P = 0.01) were identified as major learning-associated morbidities of robotic gastrectomy. Previous experience on laparoscopic surgery and mode of training influenced progression in the learning curve.

CONCLUSIONS

This is the first study suggesting that technical immaturity substantially affects the surgical outcomes of robotic gastrectomy and that robotic gastrectomy is a complex procedure with a significant learning curve that has implications for physician training and credentialing.

Motivations for and Challenges in the Development of Global Medical Curricula: A Scoping Review

PURPOSE

The aim of this scoping review is to understand the motivations for the creation of global medical curricula, summarize methods that have been used to create these curricula, and understand the perceived premises for the creation of these curricula.

METHOD

In 2018, the authors used a comprehensive search strategy to identify papers on existing efforts to create global medical curricula published from 1998 to March 29, 2018, in the following databases: MEDLINE; MEDLINE Epub Ahead of Print, In-Process, and Other Non-Indexed Citations; Embase; Cochrane Central Register of Controlled Trials; Cochrane Database of Systematic Reviews; PsycINFO; CINAHL; ERIC; Scopus; African Index Medicus; and LILACS. There were no language restrictions. Two independent researchers applied the inclusion and exclusion criteria. Demographic data were abstracted from publications and summarized. The stated purposes, methods used for the development, stated motivations, and reported challenges of curricula were coded.

RESULTS

Of the 18,684 publications initially identified, 137 met inclusion criteria. The most common stated purposes for creating curricula were to define speciality-specific standards (50, 30%), to harmonize training standards (38, 23%), and to improve the quality or safety of training (31, 19%). The most common challenges were intercountry variation (including differences in health care systems, the operationalization of medical training, and sociocultural differences; 27, 20%), curricular implementation (20, 15%), and the need for a multistakeholder approach (6, 4%). Most curricula were developed by a social group (e.g., committee; 30, 45%) or Delphi or modified Delphi process (22, 33%).

CONCLUSIONS

The challenges of intercountry variation, the need for a multistakeholder approach, and curricular implementation need to be considered if concerns about curricular relevance are to be addressed. These challenges undoubtedly impact the uptake of global medical curricula and can only be addressed by explicit efforts to make curricula applicable to the realities of diverse health care settings.

An interdisciplinary team-training protocol for robotic gynecologic surgery improves operating time and costs: analysis of a 4-year experience in a university hospital setting

Main aim of this study is to assess the effect of a structured, interdisciplinary, surgical, team-training protocol in robotic gynecologic surgery, with the gradual integration of an advanced nurse practitioner. Data from all robotic surgical procedures were prospectively acquired. The surgical team consisted of one experienced surgeon and two surgical fellows and the scrub nurse team from three advance nurse practitioners, specialized in robotic surgery. The training was performed in a four-phase manner over 4 years and included theoretical training, hands-on training and team-communication skills enhancement. Scrub nurses increasingly adopted an active role during surgery. For a period of 4 years, 175 patients could be included in the analysis. All of them underwent a robotic gynecologic procedure. Mean docking time decreased from 45.3 to 27.3 min (p < 0.001), mean operating time from 235 to 179 min (p = 0.0071) and costs per case from 17,891 to 14,731 Swiss Francs (p = 0.035). There were no statistically significant changes in perioperative complications and conversions to laparotomy. An interdisciplinary long-term training protocol for high specialized robotic surgery within a “fixed” team with the gradually addition of an advanced study nurse improves the efficacy of the procedure in terms of time and costs. Although the surgery is performed quicker, the same performance and quality of surgical care could be reached.

See Like an Expert: Gaze-Augmented Training Enhances Skill Acquisition in a Virtual Reality Robotic Suturing Task

Introduction: The da Vinci Skills Simulator (DVSS) is an effective platform for robotic skills training. Novel training methods using expert gaze patterns to guide trainees have demonstrated superiority to traditional instruction. Portable head-mounted eye-trackers (HMET) offer the opportunity for eye tracking technology to enhance surgical robotic simulation training. Objective: To evaluate if training guided by expert gaze patterns can improve trainee performance over standard movement training techniques during robotic simulation. Methods: Medical students were recruited and randomized into gaze training (GT, n = 9) and movement training (MT, n = 8) groups. First, the participants reviewed an instructional video, with the GT group emulating expert gaze patterns and the MT group (n = 8) standard movement-based instruction. Training consisted of 10 repetitions of "Suture Sponge 3" on the DVSS while wearing HMET; the first three repetitions were followed by group-appropriate video coaching (gaze vs movement feedback), while the remaining repetitions were without feedback. Finally, two multitasking repetitions with a secondary bell-counting task were completed. Primary outcomes included DVSS scores during training and multitasking. Secondary outcomes included metrics collected from the HMET (gaze patterns and gaze entropy). Results: Total score, efficiency, and penalties improved significantly over the training in both groups; the GT group achieved higher scores on every attempt. Total scores in the GT group were higher than the MT group postvideo review (20.3 ± 21.8 vs 3.0 ± 6.2, p = 0.047), after coaching repetitions (61.8 ± 18.8 vs 30.1 ± 26.2, p = 0.01), and at the last training attempt (73.0 ± 16.5 vs 63.1 ± 17.4, p = 0.247). During multitasking, the GT group maintained higher total scores (75 ± 10.1 vs 63.3 ± 15.3, p = 0.01), efficiency (86.3 ± 7.4 vs 77.4 ± 11.2, p = 0.009), and superior secondary task performance (error: 6.3% ± 0.06 vs 10.7% ± 0.11, p = 0.20). Gaze entropy (cognitive-load indicator) and gaze pattern analysis showed similar trends. Conclusion: Gaze-augmented training leads to more efficient movements through adoption of expert gaze patterns that withstand additional stressors.

Changes in UK renal oncological surgical practice from 2008 to 2017: implications for cancer service provision and surgical training

OBJECTIVE

To determine and analyse the temporal changes in oncological nephrectomy practice and training opportunities using data obtained from the UK British Association of Urological Surgeons nephrectomy register from 2008 to 2017.

PATIENT AND METHODS

All nephrectomies within the dataset for this time period were analysed (n = 54 251). Cases were divided into radical nephrectomy (RN), partial nephrectomy (PN) and nephroureterectomy (NU). Simple nephrectomy, donor nephrectomy and benign PN were excluded. The annual frequencies for each oncological nephrectomy method, surgical approach, grade of surgeon, hospital caseload numbers and short-term surgical outcomes were determined.

RESULTS

Reported annual nephrectomy numbers increased by 2.5-fold in the 9-year time period. The number of hospitals performing nephrectomies decreased by 22%, however, more than 40% of centres performed more than 70 cases a year. There was a trend towards a decrease in overall length of hospital stay (9 vs 5 days; P < 0.01) and decreased transfusion rates. The proportion of minimally invasive procedures increased from 57% to 75%, with nephron-sparing rates increasing from 8.9% overall to 24.8%. With regard to surgical technique, robot-assisted surgery saw a mean annual increase of 222%. Overall, there was a 10% decrease in the proportion of PNs performed by trainee surgeons.

CONCLUSIONS

Renal surgery has changed considerably with regard to volume and also surgical approach, with rates of nephron-sparing surgery and minimally invasive surgery significantly increasing. Increasing hospital centralization and institutional experience, and a shift to robot-assisted surgery appear to have contributed to the observed improved patient outcomes. The increasing utilization of robot-assisted surgery has potential implications and challenges for the training of future urology surgeons.

Robotic colorectal surgery in Australia: evolution over a decade

BACKGROUND

Despite reports of increasing adoption of robotics in colorectal surgery worldwide, data regarding its uptake in Australasia are lacking. This study examines the trends of robotic colorectal surgery in Australia during the last 10 years.

METHODS

Data from patients undergoing robotic colorectal surgery with the da Vinci robotic platform between 2010 and 2019 were obtained. Overall, numbers of specific colorectal procedures across Australia were obtained from the Medicare Benefit Schedule data over the same period. Pearson's correlation analysis was used to determine the statistical trends of overall and specific robotic colorectal procedures over time.

RESULTS

A total of 6110 robotic general surgery procedures were performed across Australia during the study period. Of these, 3522 (57.6%) were robotic colorectal procedures. An increasing trend of overall robotic colorectal procedures was seen over 10 years (Pearson's coefficient of 0.875; P = 0.001). While this applied to both the public and private sectors, 90.7% of the procedures were undertaken in the private sector. Restorative rectal resections, rectopexies, and right hemicolectomies accounted for 82.6% of the robotic colorectal procedures performed during this period with an increasing trend seen over time for each intervention. Moreover, a robotic approach was utilized in 12.5%, 41.0% and 9.0% of all restorative rectal resections, rectopexies and right hemicolectomies undertaken in Australia during 2019, respectively.

CONCLUSION

Robotic colorectal surgery has increased dramatically in Australia over the last 10 years, especially in the private sector. Penetration of robotic colorectal surgery in the public healthcare system will require focussed cost-benefit evaluations and governmental investment.

Procedural virtual reality simulation training for robotic surgery: a randomised controlled trial

Background

Virtual reality (VR) training is widely used for surgical training, supported by comprehensive, high-quality validation. Technological advances have enabled the development of procedural-based VR training. This study assesses the effectiveness of procedural VR compared to basic skills VR in minimally invasive surgery.

Methods

26 novice participants were randomised to either procedural VR (n = 13) or basic VR simulation (n = 13). Both cohorts completed a structured training programme. Simulator metric data were used to plot learning curves. All participants then performed parts of a robotic radical prostatectomy (RARP) on a fresh frozen cadaver. Performances were compared against a cohort of 9 control participants without any training experience. Performances were video recorded and assessed blindly using GEARS post hoc.

Results

Learning curve analysis demonstrated improvements in technical skill for both training modalities although procedural training was associated with greater training effects.

Any VR training resulted in significantly higher GEARS scores than no training (GEARS score 11.3 ± 0.58 vs. 8.8 ± 2.9, p = 0.002). Procedural VR training was found to be more effective than both basic VR training and no training (GEARS 11.9 ± 2.9 vs. 10.7 ± 2.8 vs. 8.8 ± 1.4, respectively, p = 0.03).

Conclusions

This trial has shown that a structured programme of procedural VR simulation is effective for robotic training with technical skills successfully transferred to a clinical task in cadavers. Further work to evaluate the role of procedural-based VR for more advanced surgical skills training is required.

Electronic supplementary material

The online version of this article (10.1007/s00464-020-08197-w) contains supplementary material, which is available to authorized users.

Utilising an Accelerated Delphi Process to Develop Guidance and Protocols for Telepresence Applications in Remote Robotic Surgery Training

Context

The role of robot-assisted surgery continues to expand at a time when trainers and proctors have travel restrictions during the coronavirus disease 2019 (COVID-19) pandemic.

Objective

To provide guidance on setting up and running an optimised telementoring service that can be integrated into current validated curricula. We define a standardised approach to training candidates in skill acquisition via telepresence technologies. We aim to describe an approach based on the current evidence and available technologies, and define the key elements within optimised telepresence services, by seeking consensus from an expert committee comprising key opinion leaders in training.

Evidence acquisition

This project was carried out in phases: a systematic review of the current literature, a teleconference meeting, and then an initial survey were conducted based on the current evidence and expert opinion, and sent to the committee. Twenty-four experts in training, including clinicians, academics, and industry, contributed to the Delphi process. An accelerated Delphi process underwent three rounds and was completed within 72 h. Additions to the second- and third-round surveys were formulated based on the answers and comments from the previous rounds. Consensus opinion was defined as ≥80% agreement.

Evidence synthesis

There was 100% consensus regarding an urgent need for international agreement on guidance for optimised telepresence. Consensus was reached in multiple areas, including (1) infrastructure and functionality; (2) definitions and terminology; (3) protocols for training, communication, and safety issues; and (4) accountability including ethical and legal issues. The resulting formulated guidance showed good internal consistency among experts, with a Cronbach alpha of 0.90.

Conclusions

Using the Delphi methodology, we achieved international consensus among experts for development and content validation of optimised telepresence services for robotic surgery training. This guidance lays the foundation for launching telepresence services in robotic surgery. This guidance will require further validation.

Patient summary

Owing to travel restrictions during the coronavirus disease 2019 (COVID-19) pandemic, development of remote training and support via telemedicine is becoming increasingly important. We report a key opinion leader consensus view on a standardised approach to telepresence.

Robotic Surgery Training: Current Trends and Future Directions

The use of robotic surgery in urology has grown exponentially in the past 2 decades, but robotic surgery training has lagged behind. Most graduating residents report a lack of comfort independently performing common robotic urologic surgeries, despite an abundance of available resources. There is a general consensus on the key components of a comprehensive robotics curriculum, and well-validated tools have been developed to assess trainee competency. However, no single curriculum has emerged as the gold standard on which individual programs can build their own robotics curricula.

European Society of Coloproctology Colorectal Robotic Surgery Training for the Trainers Course - the first pilot experience

AIM

Currently, there is no established colorectal specific robotic surgery Train the Trainer (TTT) course. The aim was to develop and evaluate such a course which can then be further developed to be incorporated within the planned European Society of Coloproctology (ESCP)/European School of Coloproctology (ESC) robotic colorectal surgery training curriculum.

METHOD

After identifying the need for such a course within a training programme, the course was developed by a subgroup of the ESCP/ESC. A scoping literature review was performed and the content and materials for the course were developed by a team consisting of two gastroenterologists with a combined experience of 30 years of facilitating TTT courses, a robotic surgeon and proctor with laparoscopic TTT faculty experience and experienced robotic and laparoscopic colorectal trainers. The course was evaluated by asking delegates to complete pre- and post-course questionnaires.

RESULTS

There were eight delegates on the course from across Europe. Delegates increased their knowledge of each of the course learning objectives and identified learning points in order to change practice. The feedback from the delegates of the course was positive across several areas and all felt that they had achieved their own personal objectives in attending the course.

CONCLUSION

This pilot robotic colorectal TTT course has achieved its aim and demonstrated many positives. There is a need for such a course and the evaluation processes have provided opportunities for reflection, which will allow the development/tailoring of future robotic colorectal TTT courses to help develop robotic training further.