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Teleoperated robotic systems have introduced more intuitive control for minimally invasive surgery, but the optimal method for training remains unknown. Recent motor learning studies have demonstrated that exaggeration of errors helps trainees learn to perform tasks with greater speed and accuracy. We hypothesized that training in a force field that pushes the user away from a desired path would improve their performance on a virtual reality ring-on-wire task. Thirty-eight surgical novices trained under a no-force, guidance, or error-amplifying force field over five days. Completion time, translational and rotational path error, and combined error-time were evaluated under no force field on the final day. The groups significantly differed in combined error-time, with the guidance group performing the worst. Error-amplifying field participants did not plateau in their performance during training, suggesting that learning was still ongoing. Guidance field participants had the worst performance on the final day, confirming the guidance hypothesis. Observed trends also suggested that participants who had high initial path error benefited more from guidance. Error-amplifying and error-reducing haptic training for robot-assisted telesurgery benefits trainees of different abilities differently, with our results indicating that participants with high initial combined error-time benefited more from guidance and error-amplifying force field training.

Trial Design: This was a randomized controlled trial., Background: Intraoperative errors correlate with surgeon skill and skill declines with intervals of inactivity. The goals of this research were to identify the optimal virtual reality (VR) warm-up curriculum to prime a surgeon's technical skill and validate benefit in the operating room., Materials and Methods: Surgeons were randomized to receive six trial sessions of a designated set of VR modules on the da Vinci Skills Simulator to identify optimal VR warm-up curricula to prime technical skill. After performing their curricula, warm-up effect was assessed based on performance on a criterion task. The optimal warm-up curriculum was chosen from the group with the best task time and video review-based technical skill. Robot-assisted surgery-experienced surgeons were then recruited to either receive or not receive warm-up before surgery. Skill in the first 15 min of surgery was assessed by blinded surgeon and crowdworker review as well as tool motion metrics. The intervention was performing VR warm-up before human robot-assisted surgery. Warm-up effect was measured using objective performance metrics and video review using the Global Evaluative Assessment of Robotic Skills tool. Linear mixed effects models with a random intercept for each surgeon and nonparametric modified Friedman tests were used for analysis., Results: The group performing only a Running Suture task on the simulator was on average 31.3 s faster than groups performing other simulation tasks and had the highest Global Evaluative Assessment of Robotic Skills scores from 41 surgeons who participated. This was chosen as the optimal curriculum. Thereafter, 34 surgeons completed 347 surgeries with corresponding video and tool motion data. No statistically significant differences in skill were observed with the warm-up intervention., Conclusions: We conclude that a robotic VR warm-up before performing the early stages of surgery does not impact the technical skill of the surgeon., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Purpose: Summary score metrics, either from crowds of non-experts, faculty surgeons or from automated performance metrics, have been trusted as the prevailing method of reporting surgeon technical skill. The aim of this paper is to learn whether there exist significant fluctuations in the technical skill assessments of a surgeon throughout long durations of surgical footage., Methods: A set of 12 videos of robotic surgery cases from common human patient robotic surgeries were used to evaluate the perceived technical skill at each individual minute of the surgical videos, which were originally 12-15 min in length. A linear mixed-effects model for each video was used to compare the ratings of each minute to those from every other minute in order to learn whether a change in scores over time can be detected and reliably measured apart from inter- and intrarater variation., Results: Modeling the change over time of the global evaluative assessment of robotic skills scores significantly contributed to the prediction models for 11 of the 12 surgeons. This demonstrates that measurable changes in technical skill occur over time during robotic surgery., Conclusion: The findings from this research raise questions about the optimal duration of footage needed to be evaluated to arrive at an accurate rating of surgical technical skill for longer procedures. This may imply non-negligible label noise for supervised machine learning approaches. In the future, it may be necessary to report a surgeon's skill variability in addition to their mean score to have proper knowledge of a surgeon's overall skill level.

Background: Robot-assisted laparoscopic extravesical ureteral reimplantation (RALUR-EV) is a minimally invasive alternative to open surgery. We have previously reported retrospective outcomes from our study group, and herein provide an updated prospective analysis with a focus on success rate, surgical technique, and complications among surgeons who have overcome the initial learning curve., Objective: To assess the safety and efficacy of RALUR-EV in children, among experienced surgeons., Design and Methods: We reviewed our prospective database of children undergoing RALUR-EV by pediatric urologists at eight academic centers from 2015 to 2017. Radiographic success was defined as absence of vesicoureteral reflux (VUR) on postoperative voiding cystourethrogram. Complications were graded using the Clavien scale. Univariate regression analysis was performed to assess for association among various patient and technical factors and radiographic failure., Results: In total, 143 patients were treated with RALUR-EV for primary VUR (87 unilateral, 56 bilateral; 199 ureters). The majority of ureters (73.4%) had grade III or higher VUR preoperatively. Radiographic resolution was present in 93.8% of ureters, as shown in the summary table. Ureteral complications occurred in five ureters (2.5%) with mean follow-up of 7.4 months (SD 4.0). Transient urinary retention occurred in four patients following bilateral procedure (7.1%) and in no patients after unilateral. On univariate analysis, there were no patient or technical factors associated with increased odds of radiographic failure., Discussion: We report a radiographic success rate of 93.8% overall, and 94.1% among children with grades III-V VUR. In contemporary series, alternate management options such as endoscopic injection and open UR have reported radiographic success rates of 90% and 93.5% respectively. We were unable to identify specific patient or technical factors that influenced outcomes, although immeasurable factors such as tissue handling and intraoperative decision-making could not be assessed. Ureteral complications requiring operative intervention were rare and occurred with the same incidence reported in a large open series. Limitations include lack of long-term follow-up and absence of radiographic follow-up on a subset of patients., Conclusions: Radiographic resolution of VUR following RALUR is on par with contemporary open series, and the incidence of ureteral complications is low. RALUR should be considered as one of several viable options for management of VUR in children., (Copyright © 2018. Published by Elsevier Ltd.)

Objective: To report a novel approach of pediatric robot-assisted redo pyeloplasty with buccal mucosa graft (BMG)., Methods: An Institutional Review Board-approved retrospective review of all patients undergoing robot-assisted redo pyeloplasty with BMG at our institution was performed., Operative Details: For all patients, the following ports were used: one 8.5 mm camera, two 8 mm robotic, and one 5 mm assistant. Initial dissection was performed laparoscopically and robotically, and the ureter was incised longitudinally along the anterior surface. The robot was undocked, and BMG was harvested from the inner cheek. The robot was then redocked, and grafts were delivered via the 8 mm robotic port and anastomosed as anterior onlay grafts using 5-0 or 6-0 absorbable monofilament suture. Omentum was quilted over the graft as a vascular backing. Ureteral stents were placed intraoperatively and left in situ for 8 weeks. Foley catheters were removed on postoperative day 3. All patients received intravenous ampicillin and gentamicin preoperatively, with antibiotics discontinued within 24 hours., Results: Three patients underwent robot-assisted redo pyeloplasty with BMG. Patient characteristics are seen in Table 1. Mean number of prior surgeries for ureteropelvic junction obstruction repair was 2 (1-3), and mean length of stricture was 4.3 cm (2.5-6). At a median follow-up of 10 months (5-26), all patients are asymptomatic with stable or improved ultrasound., Conclusion: Robot-assisted redo pyeloplasty with BMG is safe and feasible in the pediatric population. Long-term follow-up is needed to determine the durability of these grafts., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Robotic techniques are increasingly being used for reconstructive procedures in the pediatric population., Objective: The present study reported the functional and perioperative outcomes of a multi-institutional cohort of pediatric patients who underwent robotic-assisted laparoscopic Mitrofanoff appendicovesicostomy (RALMA)., Study Design: Pediatric patients who underwent RALMA at five different centers were included. Positioning is shown (Summary Figure). Demographics were gathered, and intraoperative parameters included concomitant procedures, detrusor tunnel length, estimated blood loss (EBL) and operative time. Perioperative outcomes included length of hospital stay (LOS), morphine use and 30-day complications. Outcomes were reported in terms of stomal continence and surgical revisions., Results: Eighty-eight patients with a mean age of 10.4 ± 4.0 years were included in the analysis. Median follow-up was 29.5 months (IQR 11.8-45.0). Bladder augmentation was performed concomitantly in 15 (17%) patients, and bladder neck procedures in 34 (39%). Mean detrusor tunnel length was 3.9 ± 1.0 cm, EBL was 54 ± 70 ml, and operative time was 424 ± 120 min. Postoperatively, mean LOS was 5.2 ± 2.8 days. Patients who underwent concomitant augmentation had higher EBL and operative times (both P < 0.05). At 90 days, complications occurred in 26 patients (29.5%) with six Clavien grade ≥3 (6.8%). During follow-up, 11 (12.5%) patients required appendicovesicostomy revision. Regarding functional outcomes, 75 (85.2%) patients were initially continent. After additional procedures, 81 (92.0%) patients were continent at last follow-up., Discussion: Compared to previous open series, initial stomal continence rates with RALMA were acceptable, with a minority of patients requiring subsequent procedures to manage complications and achieve continence., Conclusion: RALMA is safe and effective in a pediatric population with regard to perioperative complications and stomal continence., (Copyright © 2016 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.)

Background: Robotic-assisted gynecologic surgery is common, but requires unique training. A validated assessment tool for evaluating trainees' robotic surgery skills is Robotic-Objective Structured Assessments of Technical Skills., Objective: We sought to assess whether crowdsourcing can be used as an alternative to expert surgical evaluators in scoring Robotic-Objective Structured Assessments of Technical Skills., Study Design: The Robotic Training Network produced the Robotic-Objective Structured Assessments of Technical Skills, which evaluate trainees across 5 dry lab robotic surgical drills. Robotic-Objective Structured Assessments of Technical Skills were previously validated in a study of 105 participants, where dry lab surgical drills were recorded, de-identified, and scored by 3 expert surgeons using the Robotic-Objective Structured Assessments of Technical Skills checklist. Our methods-comparison study uses these previously obtained recordings and expert surgeon scores. Mean scores per participant from each drill were separated into quartiles. Crowdworkers were trained and calibrated on Robotic-Objective Structured Assessments of Technical Skills scoring using a representative recording of a skilled and novice surgeon. Following this, 3 recordings from each scoring quartile for each drill were randomly selected. Crowdworkers evaluated the randomly selected recordings using Robotic-Objective Structured Assessments of Technical Skills. Linear mixed effects models were used to derive mean crowdsourced ratings for each drill. Pearson correlation coefficients were calculated to assess the correlation between crowdsourced and expert surgeons' ratings., Results: In all, 448 crowdworkers reviewed videos from 60 dry lab drills, and completed a total of 2517 Robotic-Objective Structured Assessments of Technical Skills assessments within 16 hours. Crowdsourced Robotic-Objective Structured Assessments of Technical Skills ratings were highly correlated with expert surgeon ratings across each of the 5 dry lab drills (r ranging from 0.75-0.91)., Conclusion: Crowdsourced assessments of recorded dry lab surgical drills using a validated assessment tool are a rapid and suitable alternative to expert surgeon evaluation., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Introduction: Fibroepithelial polyps of the ureter are a rare cause of asymptomatic and symptomatic upper urinary tract obstruction in children. While these lesions can often be managed endoscopically, large or multifocal polyps may preclude such an approach., Objective: We aim to describe our institutional experience with robot-assisted laparoscopic treatment of ureteral polyps and show that a robotic approach is an effective alternative for large or multifocal polyps., Materials and Methods: Four children were identified with ureteral polyps over a 5-year period and underwent transperitoneal robot-assisted laparoscopic excision. Patients presented with flank pain and/or worsening hydronephrosis. All patients were evaluated preoperatively with ultrasound and Tc99m-mercaptoacetyltriglycine (MAG3) diuretic renogram or MR urogram. Retrograde pyelography corroborated the diagnosis of ureteral polyps. We reviewed the charts of these patients and compared the specific robotic approach for each patient, length of hospitalization, surgical complications, need for additional procedures, and resolution of symptoms and hydronephrosis., Results: In one patient, more than 20 polyps were identified over a long ureteral segment and all were excised; for the remaining three patients, 1 to 2 polyps were found. Mean postoperative length of stay was 1.5 days. One patient developed a ureteral stricture requiring repeat ureteroureterostomy, and another patient required repeat retrograde pyelography for gross hematuria that occurred several months after surgery. No polyps or obstruction was observed on retrograde pyelography in these patients. Mean duration of follow-up was 29 months (9-62 months). Symptoms and degree of hydronephrosis have improved in the three patients who have been followed for at least 12 months., Conclusions: Robot-assisted laparoscopy is a safe and feasible alternative to endoscopic treatment of fibroepithelial ureteral polyps. The robotic platform may be preferred in cases of multifocal or large ureteral polyps, or in cases in which a concomitant ureteropelvic junction narrowing may be present.

Background: A surgeon's skill in the operating room has been shown to correlate with a patient's clinical outcome. The prompt accurate assessment of surgical skill remains a challenge, in part, because expert faculty reviewers are often unavailable. By harnessing the power of large readily available crowds through the Internet, rapid, accurate, and low-cost assessments may be achieved. We hypothesized that assessments provided by crowd workers highly correlate with expert surgeons' assessments., Materials and Methods: A group of 49 surgeons from two hospitals performed two dry-laboratory robotic surgical skill assessment tasks. The performance of these tasks was video recorded and posted online for evaluation using Amazon Mechanical Turk. The surgical tasks in each video were graded by (n=30) varying crowd workers and (n=3) experts using a modified global evaluative assessment of Robotic Skills (GEARS) grading tool, and the mean scores were compared using Cronbach's alpha statistic., Results: GEARS evaluations from the crowd were obtained for each video and task and compared with the GEARS ratings from the expert surgeons. The crowd-based performance scores agreed with the performance assessments by experts with a Cronbach's alpha of 0.84 and 0.92 for the two tasks, respectively., Conclusion: The assessment of surgical skill by crowd workers resulted in a high degree of agreement with the scores provided by expert surgeons in the evaluation of basic robotic surgical dry-laboratory tasks. Crowd responses cost less and were much faster to acquire. This study provides evidence that crowds may provide an adjunctive method for rapidly providing feedback of skills to training and practicing surgeons.

Background: Objective quantification of surgical skill is imperative as we enter a healthcare environment of quality improvement and performance-based reimbursement. The gold standard tools are infrequently used due to time-intensiveness, cost inefficiency, and lack of standard practices. We hypothesized that valid performance scores of surgical skill can be obtained through crowdsourcing., Methods: Twelve surgeons of varying robotic surgical experience performed live porcine robot-assisted urinary bladder closures. Blinded video-recorded performances were scored by expert surgeon graders and by Amazon's Mechanical Turk crowdsourcing crowd workers using the Global Evaluative Assessment of Robotic Skills tool assessing five technical skills domains. Seven expert graders and 50 unique Mechanical Turkers (each paid $0.75/survey) evaluated each video. Global assessment scores were analyzed for correlation and agreement., Results: Six hundred Mechanical Turkers completed the surveys in less than 5 hours, while seven surgeon graders took 14 days. The duration of video clips ranged from 2 to 11 minutes. The correlation coefficient between the Turkers' and expert graders' scores was 0.95 and Cronbach's Alpha was 0.93. Inter-rater reliability among the surgeon graders was 0.89., Conclusion: Crowdsourcing surgical skills assessment yielded rapid inexpensive agreement with global performance scores given by expert surgeon graders. The crowdsourcing method may provide surgical educators and medical institutions with a boundless number of procedural skills assessors to efficiently quantify technical skills for use in trainee advancement and hospital quality improvement.

Introduction: Robot-assisted laparoscopic pyeloplasty (RALP) has been gaining acceptance among pediatric urologists. Over 300 have been described in the literature, but few studies have evaluated the role of RALP in infants alone., Objective: We sought to examine the operative experience and outcomes of RALP in a cohort of infants treated at multiple institutions across the United States. Our primary aim was to describe the safety and efficacy of RALP within this cohort. We recognize the challenges of performing minimally invasive surgery in small patients. In our paper, we address some technical considerations for the infant population., Study Design: This multi-centered observational study collected data on subjects one year of age or less who underwent RALP between April 2006 and July 2012 at five institutions. The primary outcome was resolution of hydronephrosis, and secondary outcomes included surgical time and complications., Results: A total of 60 patients (62 procedures) underwent RALP by six surgeons during the study period. All surgeons had > 5 years of experience beyond fellowship training. Mean surgical age was 7.3 months (SD ± 1.7 mo), 56 patients (95%) were diagnosed prenatally, and 59 patients (95%) had follow up imaging. Of these patients, 91% showed resolution or improvement of hydronephrosis. Two patients had recurrent obstruction and required additional surgery. Mean surgical time was 3 hours 52 minutes (SD ± 43 minutes). Seven (11%) patients reported intra-operative or immediate post-operative complications., Discussion: This series found a 91% success rate for reduction or resolution of hydronephrosis, and an 11% complication rate. This is equivalent to modern series comparing open pyeloplasty to pure laparoscopic and robotic-assisted laparoscopic pyeloplasty, which report success rates ranging from 70-96%, and complication rates ranging from 0-24% for open pyeloplasty. We lacked a standardized technique amongst institutions. This was not surprising since there are not established technical benchmarks for this surgery. However, we specified multiple technical considerations for this unique patient population., Conclusion: The advantages of using robot-assistance to perform pyeloplasty in infants remain to be defined. This study cannot make that assessment due to small sample size. Nonetheless, this cohort is the largest robotic pyeloplasty series in infants to date. Seeing an excellent success rate and a low complication rate in this infant cohort is encouraging., (Copyright © 2015 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.)

Background: Crowdsourcing is the practice of obtaining services from a large group of people, typically an online community. Validated methods of evaluating surgical video are time-intensive, expensive, and involve participation of multiple expert surgeons. We sought to obtain valid performance scores of urologic trainees and faculty on a dry-laboratory robotic surgery task module by using crowdsourcing through a web-based grading tool called Crowd Sourced Assessment of Technical Skill (CSATS)., Methods: IRB approval was granted to test the technical skills grading accuracy of Amazon.com Mechanical Turk™ crowd-workers compared to three expert faculty surgeon graders. The two groups assessed dry-laboratory robotic surgical suturing performances of three urology residents (PGY-2, -4, -5) and two faculty using three performance domains from the validated Global Evaluative Assessment of Robotic Skills assessment tool., Results: After an average of 2 hours 50 minutes, each of the five videos received 50 crowd-worker assessments. The inter-rater reliability (IRR) between the surgeons and crowd was 0.91 using Cronbach's alpha statistic (confidence intervals=0.20-0.92), indicating an agreement level between the two groups of "excellent." The crowds were able to discriminate the surgical level, and both the crowds and the expert faculty surgeon graders scored one senior trainee's performance above a faculty's performance., Conclusion: Surgery-naive crowd-workers can rapidly assess varying levels of surgical skill accurately relative to a panel of faculty raters. The crowds provided rapid feedback and were inexpensive. CSATS may be a valuable adjunct to surgical simulation training as requirements for more granular and iterative performance tracking of trainees become mandated and commonplace.

Objective: Extravesical robot-assisted laparoscopic ureteral reimplantation (RALUR) is a popular alternative to open surgery. We report our experience with RALUR and evaluate clinical variables as predictors for failure., Methods: We retrospectively evaluated the records of patients who underwent RALUR by a single surgeon for treatment of primary vesicoureteral reflux. Clinical and demographic variables were determined. Clinical variables were compared with surgical outcomes using the Student two-tailed type 2 t test., Results: Fifty patients underwent a combined 78 extravesical RALURs. Median (range) age was 6.2 (1.9-18.0) years; median (range) preoperative reflux grade was 3 (0-5). Dysfunctional elimination syndrome (DES) was present in 32 (64%). Ten (20%) patients had prior deflux, and two (4%) had prior ureteroneocystostomy on the ipsilateral side. Postoperative cystogram was performed in 100% at a median (range) of 55 (27-133) days. Median (range) follow-up was 286 (27-2238) days. Febrile urinary tract infection occurred in five (10%), none of whom had reflux on initial follow-up postoperative cystogram. All five had a history of DES and were female. Six complications occurred in five (10%) patients, including ileus (2), ureteral obstruction (2), ureteral injury (1), and perinephric fluid collection (1). Transient urinary retention occurred in one. Five of 22 (22.7%) patients undergoing unilateral surgery had contralateral de novo reflux. Six of 78 ureters (7.7%) had persistent reflux postoperatively. Neither persistent nor de novo reflux was associated with any of the clinical variables assessed., Conclusions: RALUR is an effective and safe option for patients with primary vesicoureteral reflux requiring surgery., (Copyright © 2014 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.)

The rapid adoption of robotic assisted surgery challenges the pace at which adequate robotic training can occur due to access limitations to the da Vinci robot. Thirty medical students completed a randomized controlled trial evaluating whether the Raven robot could be used as an alternative training tool for the Fundamentals of Laparoscopic Surgery (FLS) block transfer task on the da Vinci robot. Two groups, one trained on the da Vinci and one trained on the Raven, were tested on a criterion FLS block transfer task on the da Vinci. After robotic FLS block transfer proficiency training there was no statistically significant difference between path length (p=0.39) and economy of motion scores (p=0.06) between the two groups, but those trained on the da Vinci did have faster task times (p=0.01). These results provide evidence for the value of using the Raven robot for training prior to using the da Vinci surgical system for similar tasks.