Tag Archive for: validation


Article of the Week: Robotic Surgery – Development Of A Standardised Training Curriculum

Every Week the Editor-in-Chief selects the Article of the Week from the current issue of BJUI. The abstract is reproduced below and you can click on the button to read the full article, which is freely available to all readers for at least 30 days from the time of this post.

In addition to the article itself, there is an accompanying editorial written by a prominent member of the urological community. This blog is intended to provoke comment and discussion and we invite you to use the comment tools at the bottom of each post to join the conversation.

If you only have time to read one article this week, it should be this one.

Development Of A Standardised Training Curriculum For Robotic Surgery: A Consensus Statement From An International Multidisciplinary Group Of Experts

Kamran Ahmed, Reenam Khan, Alexandre Mottrie1, Catherine Lovegrove, Ronny Abaza2, Rajesh Ahlawat3, Thomas Ahlering4, Goran Ahlgren5, Walter Artibani6, Eric Barret7, Xavier Cathelineau7, Ben Challacombe, Patrick Coloby8, Muhammad S. KhanJacques Hubert9, Maurice Stephan Michel10, Francesco Montorsi11, Declan Murphy12Joan Palou13, Vipul Patel14, Pierre-Thierry Piechaud15, Hendrik Van Poppel16, PascalRischmann17, Rafael Sanchez-Salas7, Stefan Siemer18, Michael Stoeckle18, Jens-Uwe Stolzenburg19, Jean-Etienne Terrier20, Joachim W. Thuroff21, Christophe Vaessen22, Henk G. Van Der Poel23, Ben Van Cleynenbreugel16, Alessandro Volpe 1,24, Christian Wagner25Peter Wiklund26, Timothy Wilson27, Manfred Wirth28, Jorn Witt26 and Prokar Dasgupta


Department of Urology, Medical Research Council (MRC) Centre for Transplantation, Kings College London, GuyHospital, London, UK, 1Department of Urology, OLV Vattikuti Robotic Surgery Institute, OLV Hospital, Aalst, Belgium, 2Department of Urology, The Ohio State University Comprehensive Cancer Center, Arthur G James Cancer Hospital Richard J Solove Research Institute, Columbus, OH, USA, 3Medanta The Medicity, Gurgaon, Haryana, India, 4Department of Urology, University of California, Irvine, Orange, CA, USA, 5Department of Urology, Lund University Hospital, Lund, Sweden, 6Urology Clinic, A.O.U.I. Verona, Verona, Italy, 7Department of Urology, Institut Mutualiste Montsouris, Paris, France, 8Service dUrologie, Centre Hospitalier Rene-Dubos, Cergy-Pontoise, France, 9Service dUrologie, CHRU Nancy, Vandoeeuvre-les-Nancy, France, 10University Hospital, Mannheim, Germany, 11Department of Urology, San Raffaele Scientic Institute, Milan, Italy, 12Peter MacCallum Cancer Centre and the Royal Melbourne Hospital, Melbourne, Vic., Australia, 13Department of Urology, Fundacio Puigvert, Universitat Autonoma de Barcelona, Barcelona, Spain, 14Global Robotics Institute, Florida Hospital Celebration Health, Celebration, FL, USA, 15Clinique Saint-Augustin, Bordeaux, France, 16Department of Urology, University Hospital, KU Leuven, Leuven, Belgium, 17Service de Chirurgie Urologique, CHU Purpan, Toulouse, France, 18Klinik fur Urologie und Kinderurologie, Universitatsklinikum des Saarlandes, Homburg/Saar, Germany, 19Department of Urology, University of Leipzig, Leipzig, Germany, 20Department of Urology, Foch Hospital, Suresnes, France, 21Department of Urology, Ulm University Medical Center, Ulm, Germany, 22Service D’Urologie et de Transplantation Réno-Pancréatique, Hôpital Pitié-Salpêtrière, Paris, France, 23Department Urology, Netherlands Cancer Institute, Amsterdam, The Netherlands, 24University of Eastern Piedmont, Novara, Italy, 25St. Antonius-Hospital Gronau, Gronau, Germany, 26Department of Oncology and Pathology, Karolinska Institute, Stockholm, Sweden, 27Division of Urology, City of Hope, Duarte, CA, USA, and 28Department of Urology, University Hospital Carl Gustav Carus, Technical University of Dresden, Dresden, Germany



To explore the views of experts about the development and validation of a robotic surgery training curriculum, and how this should be implemented.


An international expert panel was invited to a structured session for discussion. The study was of a mixed design, including qualitative and quantitative components based on focus group interviews during the European Association of Urology (EAU) Robotic Urology Section (ERUS) (2012), EAU (2013) and ERUS (2013) meetings. After introduction to the aims, principles and current status of the curriculum development, group responses were elicited. After content analysis of recorded interviews generated themes were discussed at the second meeting, where consensus was achieved on each theme. This discussion also underwent content analysis, and was used to draft a curriculum proposal. At the third meeting, a quantitative questionnaire about this curriculum was disseminated to attendees to assess the level of agreement with the key points.


In all, 150 min (19 pages) of the focus group discussion was transcribed (21 316 words). Themes were agreed by two raters (median agreement κ 0.89) and they included: need for a training curriculum (inter-rater agreement κ 0.85); identification of learning needs (κ 0.83); development of the curriculum contents (κ 0.81); an overview of available curricula (κ 0.79); settings for robotic surgery training ((κ 0.89); assessment and training of trainers (κ 0.92); requirements for certification and patient safety (κ 0.83); and need for a universally standardised curriculum (κ 0.78). A training curriculum was proposed based on the above discussions.


This group proposes a multi-step curriculum for robotic training. Studies are in process to validate the effectiveness of the curriculum and to assess transfer of skills to the operating room.

Editorial: Towards a Standardized Training Curriculum For Robotic Surgery

The work of the authors [1] towards robotic training and credentialing is much needed and should be applauded as increased scrutiny is being placed on complications associated with robotic surgery [2]. The authors held three separate meetings in 2012 and 2013 in which they identified themes, developed a training curriculum, and assessed expert agreement with their proposed curriculum. The authors’ [1]quantitative survey of 24 experts revealed that all ‘agreed’ or ‘agreed strongly’ with the proposed curriculum. The curriculum includes three areas, cognitive, psychomotor, and teamwork/communication skills, which we feel are vital for good outcomes [3]. As was noted, there are available ‘E-learning’ tools online from organisations such as the AUA and from Intuitive Surgical, and these can be further expanded and validated [4, 5]. The AUA also has recommendations for credentialing requirements that are available online.

We agree with the authors [1] that simulation should include inanimate models, which provide a good cost to benefit ratio. There are increasing numbers of inanimate models for the simulation of procedures, e.g. partial nephrectomy and pyeloplasty. One limitation of inanimate training is that the entire robotic surgical system is used and it may only be free for training on nights and weekends when the robotic systems are not being used clinically. Virtual reality simulators offer a more convenient way to become familiar with the robotic environment, but at a cost of ≈$100 000 (American dollars). Virtual reality simulation is predominantly used to develop skills for a junior trainee or a novice surgeon. However, procedure-specific and augmented-reality simulation is being developed and will greatly enhance robotic training.

The authors [1] should be applauded for offering a specific curriculum consisting of online training, an 8-day ‘discovery’ course for simulation and observation, and a 6-month fellowship for step-wise progression to ‘live’ surgical console time. As the authors note, credentialing should be based on competency and not on the number of cases logged or the duration of training alone. The duration of the fellowship should be based on the learning objectives and research/academic requirements.

In the USA, robotic surgical training is included during residency in urology and a fellowship may not be required if a graduating resident is proficient according to the programme directors’ assessment. For surgeons who have not been trained during residency, proctoring by an experienced surgeon is recommended by the AUA [5], after completing a structured robotic surgical curriculum as described in this article [1]. However, a validated curriculum and benchmarks for competency have not been established. The Fundamentals of Robotic Surgery (FRS) curriculum will be validated during the next year for a multidisciplinary curriculum with skills testing [6].

We also agree with the authors [1] that non-technical skills such as trouble-shooting, teamwork, leadership, and communication are critically important for preventing adverse events. Many if not most complications occur due to failures in patient selection, trocar positioning, and bedside assisting. Also, many complications can be traced to ‘system’ problems rather than console performance. Robotic surgery requires a proficient team to ensure good outcomes.

Currently, there are no uniform credentialing requirements to practice robotic surgery in the USA or many other countries. A validated robotic training curriculum with competency-based assessments is essential and can be integrated into residency programmes where robotic technology is readily available. Where robotic surgical volume is inadequate, fellowship programmes can provide the needed training. A validated competency-based approach offers the hope of better patient outcomes and the continued acceptance of new technologies such as robotic surgery.

Clinton D. Bahler and Chandru P. Sundaram
Department of Urology, Indiana University, Indianapolis, IN, USA





2 Alemzadeh H, Iyer RK, Raman J. Safety Implications of Robotic Surgery: Analysis of Recalls and Adverse Event Reports of da Vinci Surgical Systems. The Society of Thoracic Surgeons Annual Meeting2014; Orlando, Florida. Available at: https://www.sts.org/sites/default/les/documents/pdf/annmtg/2014AM/50AM_MonJan27.pdf. Accessed February 2015.


3 Bahler CD, Sundaram CP. Training in Robotic surgery: simulatorssurgery, and credentialing. Urol Clin North Am 2014; 41: 5819.


4 The American Urological Association. E-Learning: Urologic Robotic Surgery Course. The American Urological Association Education and Research, Inc, 2012. Available at: https://www.auanet.org/education/modules/robotic-surgery/. Accessed April 2014.


5 The American Urological Association. Standard Operating Practices (SOPS) for Urologic Robotic Surgery. The American Urological Association, 2013. Available at: https://www.auanet.org/common/pdf/about/SOP-Urologic-Robotic-Surgery.pdf. Accessed April 2014.




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