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RAPN training usually takes place in-vivo and methods vary across countries/institutions. No common system exists to objectively assess trainee capacity to perform RAPN at predetermined performance levels prior to in-vivo practice. The identification of objective performance metrics for RAPN training is a crucial starting point to improve training and surgical outcomes. The authors sought to examine the reliability, construct and discriminative validity of objective intraoperative performance metrics which best characterize the optimal and suboptimal performance of a reference approach for training novice RAPN surgeons. Seven Novice and 9 Experienced RAPN surgeons video recorded one or two independently performed RAPN procedures in the human. The videos were anonymized and two experienced urology surgeons were trained to reliably score RAPN performance, using previously developed metrics. The assessors were blinded to the performing surgeon, hospital and surgeon group. They independently scored surgeon RAPN performance. Novice and Experienced group performance scores were compared for procedure steps completed and errors made. Each group was divided at the median for Total Errors score, and subgroup scores (i.e., Novice HiErrs and LoErrs, Experienced HiErrs and LoErrs) were compared. The mean inter-rater reliability (IRR) for scoring was 0.95 (range 0.84-1). Compared with Novices, Experienced RAPN surgeons made 69% fewer procedural Total Errors. This difference was accentuated when the LoErr Expert RAPN surgeon's performance was compared with the HiErrs Novice RAPN surgeon's performance with an observed 170% fewer Total Errors. GEARS showed poor reliability (Mean IRR = 0.44; range 0.0-0.8), for scoring RAPN surgical performance. The RAPN procedure metrics reliably distinguish Novice and Experienced surgeon performances. They further differentiated performance levels within a group with similar experiences. Reliable and valid metrics will underpin quality-assured novice RAPN surgical training., (© 2023. The Author(s).)

Background: Robot-assisted partial nephrectomy (RAPN) training usually takes place in vivo, and methods vary across countries/institutions. No common system exists to objectively assess trainee ability to perform RAPN at predetermined performance levels prior to in vivo practice. The identification of objective performance metrics for RAPN training is a crucial starting point to improve training and surgical outcomes., Objective: We sought to identify objective performance metrics that best characterize a reference approach to RAPN, and obtain face and content validity from procedure experts through a modified Delphi meeting., Design, Setting, and Participants: During a series of online meetings, a core metrics team of three RAPN experts and a senior behavioral scientist performed a detailed task deconstruction of a transperitoneal left-sided RAPN procedure., Outcome Measurements and Statistical Analysis: Based on published guidelines, manufacturers' instructions, and unedited videos of RAPN, the team identified performance metrics that constitute an optimal approach for training purposes. The metrics were then subjected to an in-person modified international Delphi panel meeting with 19 expert surgeons., Results and Limitations: Eleven procedure phases, with 64 procedure steps, 43 errors, and 39 critical errors, were identified. After the modified Delphi process, the international expert panel added 13 metrics (two steps), six were deleted, and three were modified; 100% panel consensus on the resulting metrics was obtained. Limitations are that the metrics are applicable only to left-sided RAPN cases and some might have been excluded., Conclusions: Performance metrics that accurately characterize RAPN procedure were developed by a core group of experts. The metrics were then presented to and endorsed by an international panel of very experienced peers. Reliable and valid metrics underpin effective, quality-assured, structured surgical training for RAPN., Patient Summary: We organize a meeting among robot-assisted partial nephrectomy (RAPN) experts to identify and reach consensus on objective performance metrics for RAPN training. The metrics are a crucial starting point to improve and quality assure surgical training and patients' clinical outcomes., (Copyright © 2022 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Objective: To determine whether proficiency-based progression (PBP) training leads to better robotic surgical performance compared to traditional training (TT), given that the value of PBP training for learning robotic surgical skills is unclear., Materials and Methods: The PROVESA trial is a multicentric, prospective, randomized and blinded clinical study comparing PBP training with TT for robotic suturing and knot-tying anastomosis skills. A total of 36 robotic surgery-naïve junior residents were recruited from 16 training sites and 12 residency training programmes. Participants were randomly allocated to metric-based PBP training or the current standard of care TT, and compared at the end of training. The primary outcome was percentage of participants reaching the predefined proficiency benchmark. Secondary outcomes were the numbers of procedure steps and errors made., Results: Of the group that received TT, 3/18 reached the proficiency benchmark versus 12/18 of the PBP group (i.e. the PBP group were ~10 times as likely to demonstrate proficiency [P = 0.006]). The PBP group demonstrated a 51% reduction in number of performance errors from baseline to the final assessment (18.3 vs 8.9). The TT group demonstrated a marginal improvement (15.94 vs 15.44) in errors made., Conclusions: The PROVESA trial is the first prospective randomized controlled trial on basic skills training in robotic surgery. Implementation of a PBP training methodology resulted in superior surgical performance for robotic suturing and knot-tying anastomosis performance. Compared to TT, better surgical quality could be obtained by implementing PBP training for basic skills in robotic surgery., (© 2022 BJU International.)

Background: Prediction of lymph node invasion (LNI) after radical prostatectomy has been rarely assessed in robotically assisted laparoscopic radical prostatectomy (RALP) series. We aimed to develop and externally validate a pretreatment nomogram for the prediction of LNI following RALP in patients with high- and intermediate-risk prostate cancer., Methods: 1654 RALP patients were prospectively collected between 2009 and 2016 from academic and community hospitals. We included patients with intermediate- and high-risk prostate cancer who underwent pelvic lymph node dissection (e-PLND). Logistic regression analysis was applied to construct a nomogram to predict LNI. Centers were randomly assigned to the training cohort (80%) and validation cohort (20%). The discriminative accuracies were evaluated by the areas under the curve and by the calibration plot. The net benefit of the nomogram to predict LNI was assessed by decision curve analysis and a cut-off was proposed., Results: In total, 14% of the patients in our cohort had pN1 disease. Applying logistic regression analysis, the following covariates were chosen to develop the nomogram: initial PSA, clinical T stage, biopsy Gleason sum, and proportion of positive biopsy cores. The nomogram showed a median discriminative accuracy of 73% and excellent calibration. The net benefit of the model ranged between 7% and 51% predicted risk of LNI. A cut-off to perform e-PLND was set at 7%. This would permit a 29% of avoidable e-PLND, missing 9.4% of patients with LNI., Conclusions: We developed and externally validated a nomogram to predict LNI in patients treated with RALP from a prospective, multi-institutional, nationwide series. A risk of LNI > 7% is proposed as cut-off above which e-PLND is recommended., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objectives: To explore the views of experts about the development and validation of a robotic surgery training curriculum, and how this should be implemented., Materials and Methods: 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., Results: 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., Conclusion: 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., (© 2015 The Authors BJU International © 2015 BJU International Published by John Wiley & Sons Ltd.)

Purpose: The determination of an optimal pivot point ([Formula: see text]) is important for instrument manipulation in minimally invasive surgery. Such knowledge is of particular importance for robotic-assisted surgery where robots need to rotate precisely around a specific point in space in order to minimize trauma to the body wall while maintaining position control. Remote center of motion (RCM) mechanisms are commonly used, where the RCM point is manually and visually aligned. If not positioned appropriately, this misalignment might lead to intolerably high forces on the body wall with increased risk of postoperative complications or instrument damage. An automated method to align the RCM with the [Formula: see text] was developed and tested., Method: Computer vision and a lightweight calibration procedure are used to estimate the optimal pivot point. One or two pre-calibrated cameras viewing the surgical scene are employed. The surgeon is asked to make short pivoting movements, applying as little torque as possible, with an instrument of choice passing through the insertion point while camera images are being recorded. The physical properties of an instrument rotating around a pivot point are exploited in a random sample consensus scheme to robustly estimate the ideal position of the RCM in the image planes. Triangulation is used to estimate the RCM position in 3D. Experiments were performed on a specially designed mockup to test the method., Results: The position of the pivot point is estimated with an average error less than 1.85 mm using two webcams placed from approximately 30 cm to 1 m away from the scene. The entire procedure was completed in a few seconds., Conclusion: In automated method to estimate the ideal position of the RCM was shown to be reliable. The method can be implemented within a visual servoing approach to automatically place the RCM point, or the results can be displayed on a screen to provide guidance to the surgeon. Further work includes the development of an image-guided alignment method and validation with in vivo experiments.

Objective: To compare functional outcomes, i.e. urinary incontinence (UI), voiding symptoms and quality of life, after open (ORP) and robot-assisted radical prostatectomy (RARP)., Patients and Methods: Between September 2009 and July 2011, 180 consecutive patients underwent radical prostatectomy; of these, 116 underwent ORP and 64 underwent RARP. We prospectively assessed the functional outcomes of each group during the first year of follow-up. We measured UI on the 3 days before surgery (24-h pad test) and daily after surgery until total continence, defined as 3 consecutive days of 0 g urine leak, was achieved. Additionally, all patients were assessed before surgery and at 1, 3, 6 and 12 months after surgery using the International Prostate Symptom Score (IPSS) and the King's Health Questionnaire (KHQ). All patients received pelvic floor muscle training until continence was achieved. Kaplan-Meier analyses and Cox regression with correction for covariates were used to compare time to continence. A Mann-Whitney U-test was used to assess IPSS and KHQ., Results: Patients in the RARP group had a significantly lower D'Amico risk group allocation and underwent more nerve-sparing surgery. Other characteristics were similar. Patients in the RARP group regained continence sooner than those in the ORP group (P = 0.007). In the RARP group, the median time to continence (16 vs 46 days, P = 0.026) was significantly shorter and the median amount of first day UI (44 vs 186 g, P < 0.01) was significantly smaller than in the ORP group. After correction for all covariates, the difference remained significant (P = 0.036, hazard ratio [HR] 1.522 (1.027-2.255). In addition, younger men, men with positive surgical margins and men without preoperative incontinence achieved continence sooner. A comparison of time to continence between groups with a sufficient number of patients (intermediate risk and/or bilateral nerve-sparing) still showed a faster return of continence after RARP, but the effect decreased in size and was nonsignificant (HR>1.2, P > 0.05). Only six patients (two in the RARP and four in the ORP group) still had UI after 1 year. Patients in the RARP group had significantly better IPSS scores at 1 (P = 0.013) and 3 (P = 0.038) months, and scored better in almost all KHQ aspects., Conclusion: In this prospective trial, patients treated with RARP tended to regain urinary continence sooner than patients treated with ORP, but in subgroup analyses statistical significance disappeared and effect size decreased dramatically, indicating that the results must be interpreted with caution., (© 2013 The Authors. BJU International © 2013 BJU International.)

Objective: The feasibility of the conceptual Intuitive Writing Interface (IWI) in robot-aided laser laparoscopic surgery has been demonstrated previously. This paper investigates the potential improvement of IWI by comparing conventional manipulation (CM) and IWI manipulation (IM) and conducting an animal experiment., Materials and Methods: Three tasks were designed that were considered to be representative of laser laparoscopic surgical procedures. All test participants used both CM and IM in all tasks. Completion time and error level of each task were taken as comparative indices and were integrated into a self-defined Index of Time and Error (ITE). Six sequential in vitro trials were carried out to investigate learning curves. In addition, nephrectomy was performed on a rabbit by employing IWI in robot-aided laser laparoscopic surgery., Results: The results showed significant advantages for IM, with shorter completion time, more successful shots, and smaller error length in the three tasks, as compared to CM. The learning curve showed a promising trend for IM. More than half of the participants performed better with IM. The animal model experiment demonstrated the clinical feasibility of IM, but at the same time revealed some limitations., Conclusions: The new IWI interface definitely improved laser laparoscopic procedures by taking advantage of familiar writing skills. With its flexibility of implementation and ease of use, IWI has clear potential for use in laser laparoscopic procedures.