Pilot Validation Study of the European Association of Urology Robotic Training Curriculum

3. Results

The characteristics and previous robotic experience of the participants are reported in Table 1 . Most participants had minimal or no previous experience of simulation-based training. The median times of involvement as a table assistant and a console surgeon at baseline were 9.5 mo (IQR 5.75–16 mo) and 4 mo (IQR 0–6.5 mo), respectively.

All participants completed the required e-learning module and passed the final test for assessment of theoretical knowledge. All fellows observed and assisted in the recommended number of procedures (>12 cases) during the first 3 wk of the curriculum, participated successfully in all activities during the intensive week of laboratory training, and completed the 8 wk of supervised modular training. The median number of RARPs they were involved in as console surgeons during modular training was 18 (IQR 14–36).

The overall scores obtained by participants for performance of four different dVSS tasks at baseline, during the training program (weeks 4 and 5), and at the end of the curriculum are reported in Figure 2 . For all exercises the overall score significantly increased over the training period (p < 0.001–0.005).

Fig. 2 Progressive improvement in overall scores for different tasks on the da Vinci surgical simulator before, during (weeks 4 and 5), and after completion of the curriculum. * Significant difference compared to overall score before the curriculum (p < 0.05).° Significant difference compared to overall score in week 4 (p < 0.05).

The GEARS scale was used by mentors to evaluate the final RARP performance of fellows ( Fig. 3 A). Good to excellent scores were obtained by 80–100% of trainees for their depth perception (median 5, IQR 4–5), bimanual dexterity (median 4.5, IQR 4–5), efficiency (median 4, IQR 3.75–5), force sensitivity (median 4, IQR 4–5), autonomy (median 4, IQR 3.75–5), and robotic control (median 5, IQR 3.75–5) skills. A procedure-specific scale was used to score the performance of fellows for each RARP surgical step ( Fig. 3 B).

Fig. 3 Mentor assessment of robot-assisted radical prostatectomy performance at the end of the European robot-assisted urologic training curriculum using (A) the GEARS scale and (B) a procedure-specific scale.

Eight trainees (80%) were considered by their mentors able to perform a RARP independently, safely, and efficiently on completion of the curriculum. Three (30%) were considered able to perform a complex RARP independently, safely, and effectively.

The blinded video-based assessment results for RARP steps performed by each fellow and two robotic experts are shown in Table 2 . The fellows achieved an average score that was considered safe (≥10) for all surgical steps. The highest average scores were obtained for bladder detachment and urethrovesical anastomosis. When the scores for all procedural steps were assessed, eight fellows (80%) reached an average score ≥10. The two participants who did not reach an average sufficient score were residents. The robotic experts significantly outperformed the fellows overall (mean score 13.6 vs 11) and for all RARP steps except bladder detachment and endopelvic fascia incision, confirming the construct validity of the assessment ( Fig. 4 ).

Fig. 4 Comparison of robot-assisted radical prostatectomy performance between fellows and experts using a generic dedicated scoring scale (range 4–16).

The results for quantitative surveys completed at the end of curriculum are reported in Figure 5 . All fellows gave an excellent overall evaluation of the training program and felt that the curriculum was very effective in improving their console exposure, their basic robotic skills, and their ability to perform RARP.

Fig. 5 Assessment of the educational impact, face validity, feasibility, and acceptability of the European Association of Urology Robotic Training Curriculum via quantitative surveys.

This is the first study that incorporates and validates different components of a training curriculum for robot-assisted surgery at a multi-institutional level. The study demonstrates that a 12-wk structured training program including theoretical e-learning, laboratory training, and modular training in the operating room is feasible, acceptable, and effective in improving the technical robotic skills and ability of young surgeons with limited previous robotic experience to perform the surgical steps of RARP. The study also demonstrates the face validity of this curriculum.

In the last few years there has been growing interest in the field of surgical education, especially in minimally invasive laparoscopic and robotic surgery [3], [4], [9], and [10]. However, curricula for training in robotic urologic procedures have not yet been standardized and the optimal integration of simulation-based training in surgical training programs is not clearly defined or evidence-based. The definition of curricula for each surgical procedure and their validation and progressive implementation are important for accreditation of surgeons and teams for each specific intervention, with the ultimate aim of improving surgical safety and patient outcomes [5] and [11].

To date, three basic curricula for training and assessment of robotic surgeons have been developed and reported in the literature [3], [4], and [17]. It has been shown that they are valid, feasible, and effective in significantly improving basic robotic surgery skills. However, these curricula do not include modular training in the operating room and they have not been validated for specific procedures.

On the basis of these considerations, the ERUS board members designed and proposed a curriculum for RARP including simulation-based and modular console training with an expert mentor. The curriculum content was finalized in accordance with the expert opinion of robotic surgeons across various regions to ensure content validation [12] . The program is a step forward from existing approaches because it includes all the simulation training modalities available (virtual reality simulation, bench-top models, live animal surgery, and cadaveric procedures) combined with clinical training in the form of a mini-fellowship. Fellowships are actually considered a key component of training for complex urologic procedures such as RARP [18] .

An ideal training program should be feasible, acceptable, valid, and economically sustainable, with an effective educational impact [15] . Our results show that the EAU robotic training curriculum is feasible and acceptable, as all participants were very satisfied with the program and would highly recommend it to other colleagues. All modules of the curriculum were found to be useful, although the fellows subjectively found the virtual reality simulation training, the dry and wet laboratories, and the cadaver training particularly valuable. These data suggest that all these elements should ideally be integrated in training programs, although there are cost, ethical, and regulatory issues to take into account. The centralization of simulation training in an intensive week at a single, fully equipped training centre was well perceived and proved to be effective, as previously demonstrated in other studies [19] .

An effective simulation-based training program represents the ideal background for clinical training in the operating room. The concept of modular training proposed by Stolzenburg et al [14] for laparoscopic radical prostatectomy was adopted in the curriculum for progressive, proficiency-based training of a fellow through steps of increasing levels of difficulty in a surgical procedure. This strategy has the potential to overcome the problems of teaching complex surgical procedures, allowing safe training of surgeons with limited expertise and potentially accelerating their learning curve. The importance of proper mentoring for effective modular training has recently been highlighted [18] .

This pilot study showed that the EAU robotic training curriculum can effectively improve the basic robotic skills of participants, as demonstrated by the significant improvement in overall scores achieved by fellows at the end of the curriculum for all dVSS tasks. The first weeks of simulation training were found to be particularly effective in this respect, potentially allowing participants to optimize the results of subsequent training in the operating room. Importantly, at the end of the curriculum the majority of fellows were able to perform RARP with good or acceptable technical quality, as reflected by scores from mentors and blinded reviews of video-recorded surgeries. The two participants who were not deemed able to perform RARP safely and efficiently by the end of the training program were residents. This may indicate that the curriculum is more likely to be effective for urologists who have already completed their basic training in residency programs.

The curriculum also provided constructive feedback on the performance of fellows for individual procedural steps. Overall, the fellows were able to reach similar performance levels compared to expert surgeons for the easiest RARP steps, such as bladder detachment and endopelvic fascia incision. However, the experts achieved significantly better scores for challenging parts of the procedure, confirming the construct validity of the assessment. Fellows who did not reach sufficient scores for specific surgical steps will need further training before being deemed able to safely perform RARP independently.

Finally, the results indicate that the curriculum has a good educational impact, as well as face validity, defined as the extent to which the program is subjectively viewed as delivering the desired goal. In fact, the majority of the participants felt that the curriculum significantly improved their robotic skills and their ability to perform different RARP steps. However, further comparative studies and, ideally, randomized controlled trials will be needed to assess whether this curriculum is superior to traditional nonstructured training for RARP.

This study has some limitations. First, the number of participants was limited. Second, although the participants had limited previous robotic experience, they were not all completely novice to console surgery, so the results for the training program may be overestimated. The experience level of mentors was not factored in the analysis, but they were all high-volume robotic surgeons at teaching institutions. Third, modular training was not standardized and the console exposure of the participants was variable. Fourth, assessment of the technical skills of the fellows using GEARS and the procedure-specific scoring scale at the end of the training program was performed by their mentors. However, to standardize the assessment process and minimize bias due to nonblinded assessment, the mentors were informed about and educated in the use of the scoring systems. Fifth, the performance of fellows in RARP video clips was assessed using a new scoring tool. The contents of this scoring criterion were developed and validated on the basis of expert opinion. Sixth, a 3-mo training program may be too short for some fellows to achieve sufficient skills to adequately perform complex parts of the procedure. Finally, there was no specific training or proper pre- and post-training assessment of nontechnical skills.

This study represents the first step towards the definition of an ideal training program for RARP and of criteria for accreditation of surgeons for this procedure. Further studies need to be carried out to address the issues associated with certification and recertification using training curricula.

The concept of surgical training has been evolving in the last decade from the traditional concept of “see one, do one, teach one” towards better defined and standardized methodologies for surgical education based on the development of skill-based curricula [1], [2], [3], [4], and [5]. Furthermore, the development and diffusion of surgical robotic platforms are increasingly supporting the development, use, and validation of simulation-based training methods ranging from bench-top synthetic models, animal, and cadavers to high-fidelity virtual training platforms [6], [7], and [8]. Simulation-based training should be an essential part of surgical training programs to significantly improve the technical and nontechnical skills of trainees, shorten their learning curves for different procedures, and improve surgical safety [9] and [10].

Nevertheless, training for robotic techniques remains mainly unstructured. There has been a recent call by various training bodies for the development of well-organized educational curricula to increase preclinical exposure and of validated assessment tools that allow constructive feedback for performance improvement. These curricula, as well as proficiency-based credential processes, are important for improving patient safety and surgical outcomes in urological surgery [5] and [11].

On the basis of these considerations, the European Association of Urology (EAU) Robotic Urologic Section (ERUS) has designed and developed a structured training program and curriculum in urology that focuses on robot-assisted radical prostatectomy (RARP). The aim of the present study was to assess the feasibility, acceptability, face validity, and educational impact of this curriculum, and to assess improvements in performance and ability to perform RARP after completion of the curriculum.

3. Results

The characteristics and previous robotic experience of the participants are reported in Table 1 . Most participants had minimal or no previous experience of simulation-based training. The median times of involvement as a table assistant and a console surgeon at baseline were 9.5 mo (IQR 5.75–16 mo) and 4 mo (IQR 0–6.5 mo), respectively.

All participants completed the required e-learning module and passed the final test for assessment of theoretical knowledge. All fellows observed and assisted in the recommended number of procedures (>12 cases) during the first 3 wk of the curriculum, participated successfully in all activities during the intensive week of laboratory training, and completed the 8 wk of supervised modular training. The median number of RARPs they were involved in as console surgeons during modular training was 18 (IQR 14–36).

The overall scores obtained by participants for performance of four different dVSS tasks at baseline, during the training program (weeks 4 and 5), and at the end of the curriculum are reported in Figure 2 . For all exercises the overall score significantly increased over the training period (p < 0.001–0.005).

Fig. 2 Progressive improvement in overall scores for different tasks on the da Vinci surgical simulator before, during (weeks 4 and 5), and after completion of the curriculum. * Significant difference compared to overall score before the curriculum (p < 0.05).° Significant difference compared to overall score in week 4 (p < 0.05).

The GEARS scale was used by mentors to evaluate the final RARP performance of fellows ( Fig. 3 A). Good to excellent scores were obtained by 80–100% of trainees for their depth perception (median 5, IQR 4–5), bimanual dexterity (median 4.5, IQR 4–5), efficiency (median 4, IQR 3.75–5), force sensitivity (median 4, IQR 4–5), autonomy (median 4, IQR 3.75–5), and robotic control (median 5, IQR 3.75–5) skills. A procedure-specific scale was used to score the performance of fellows for each RARP surgical step ( Fig. 3 B).

Fig. 3 Mentor assessment of robot-assisted radical prostatectomy performance at the end of the European robot-assisted urologic training curriculum using (A) the GEARS scale and (B) a procedure-specific scale.

Eight trainees (80%) were considered by their mentors able to perform a RARP independently, safely, and efficiently on completion of the curriculum. Three (30%) were considered able to perform a complex RARP independently, safely, and effectively.

The blinded video-based assessment results for RARP steps performed by each fellow and two robotic experts are shown in Table 2 . The fellows achieved an average score that was considered safe (≥10) for all surgical steps. The highest average scores were obtained for bladder detachment and urethrovesical anastomosis. When the scores for all procedural steps were assessed, eight fellows (80%) reached an average score ≥10. The two participants who did not reach an average sufficient score were residents. The robotic experts significantly outperformed the fellows overall (mean score 13.6 vs 11) and for all RARP steps except bladder detachment and endopelvic fascia incision, confirming the construct validity of the assessment ( Fig. 4 ).

Fig. 4 Comparison of robot-assisted radical prostatectomy performance between fellows and experts using a generic dedicated scoring scale (range 4–16).

The results for quantitative surveys completed at the end of curriculum are reported in Figure 5 . All fellows gave an excellent overall evaluation of the training program and felt that the curriculum was very effective in improving their console exposure, their basic robotic skills, and their ability to perform RARP.

Fig. 5 Assessment of the educational impact, face validity, feasibility, and acceptability of the European Association of Urology Robotic Training Curriculum via quantitative surveys.

This is the first study that incorporates and validates different components of a training curriculum for robot-assisted surgery at a multi-institutional level. The study demonstrates that a 12-wk structured training program including theoretical e-learning, laboratory training, and modular training in the operating room is feasible, acceptable, and effective in improving the technical robotic skills and ability of young surgeons with limited previous robotic experience to perform the surgical steps of RARP. The study also demonstrates the face validity of this curriculum.

In the last few years there has been growing interest in the field of surgical education, especially in minimally invasive laparoscopic and robotic surgery [3], [4], [9], and [10]. However, curricula for training in robotic urologic procedures have not yet been standardized and the optimal integration of simulation-based training in surgical training programs is not clearly defined or evidence-based. The definition of curricula for each surgical procedure and their validation and progressive implementation are important for accreditation of surgeons and teams for each specific intervention, with the ultimate aim of improving surgical safety and patient outcomes [5] and [11].

To date, three basic curricula for training and assessment of robotic surgeons have been developed and reported in the literature [3], [4], and [17]. It has been shown that they are valid, feasible, and effective in significantly improving basic robotic surgery skills. However, these curricula do not include modular training in the operating room and they have not been validated for specific procedures.

On the basis of these considerations, the ERUS board members designed and proposed a curriculum for RARP including simulation-based and modular console training with an expert mentor. The curriculum content was finalized in accordance with the expert opinion of robotic surgeons across various regions to ensure content validation [12] . The program is a step forward from existing approaches because it includes all the simulation training modalities available (virtual reality simulation, bench-top models, live animal surgery, and cadaveric procedures) combined with clinical training in the form of a mini-fellowship. Fellowships are actually considered a key component of training for complex urologic procedures such as RARP [18] .

An ideal training program should be feasible, acceptable, valid, and economically sustainable, with an effective educational impact [15] . Our results show that the EAU robotic training curriculum is feasible and acceptable, as all participants were very satisfied with the program and would highly recommend it to other colleagues. All modules of the curriculum were found to be useful, although the fellows subjectively found the virtual reality simulation training, the dry and wet laboratories, and the cadaver training particularly valuable. These data suggest that all these elements should ideally be integrated in training programs, although there are cost, ethical, and regulatory issues to take into account. The centralization of simulation training in an intensive week at a single, fully equipped training centre was well perceived and proved to be effective, as previously demonstrated in other studies [19] .

An effective simulation-based training program represents the ideal background for clinical training in the operating room. The concept of modular training proposed by Stolzenburg et al [14] for laparoscopic radical prostatectomy was adopted in the curriculum for progressive, proficiency-based training of a fellow through steps of increasing levels of difficulty in a surgical procedure. This strategy has the potential to overcome the problems of teaching complex surgical procedures, allowing safe training of surgeons with limited expertise and potentially accelerating their learning curve. The importance of proper mentoring for effective modular training has recently been highlighted [18] .

This pilot study showed that the EAU robotic training curriculum can effectively improve the basic robotic skills of participants, as demonstrated by the significant improvement in overall scores achieved by fellows at the end of the curriculum for all dVSS tasks. The first weeks of simulation training were found to be particularly effective in this respect, potentially allowing participants to optimize the results of subsequent training in the operating room. Importantly, at the end of the curriculum the majority of fellows were able to perform RARP with good or acceptable technical quality, as reflected by scores from mentors and blinded reviews of video-recorded surgeries. The two participants who were not deemed able to perform RARP safely and efficiently by the end of the training program were residents. This may indicate that the curriculum is more likely to be effective for urologists who have already completed their basic training in residency programs.

The curriculum also provided constructive feedback on the performance of fellows for individual procedural steps. Overall, the fellows were able to reach similar performance levels compared to expert surgeons for the easiest RARP steps, such as bladder detachment and endopelvic fascia incision. However, the experts achieved significantly better scores for challenging parts of the procedure, confirming the construct validity of the assessment. Fellows who did not reach sufficient scores for specific surgical steps will need further training before being deemed able to safely perform RARP independently.

Finally, the results indicate that the curriculum has a good educational impact, as well as face validity, defined as the extent to which the program is subjectively viewed as delivering the desired goal. In fact, the majority of the participants felt that the curriculum significantly improved their robotic skills and their ability to perform different RARP steps. However, further comparative studies and, ideally, randomized controlled trials will be needed to assess whether this curriculum is superior to traditional nonstructured training for RARP.

This study has some limitations. First, the number of participants was limited. Second, although the participants had limited previous robotic experience, they were not all completely novice to console surgery, so the results for the training program may be overestimated. The experience level of mentors was not factored in the analysis, but they were all high-volume robotic surgeons at teaching institutions. Third, modular training was not standardized and the console exposure of the participants was variable. Fourth, assessment of the technical skills of the fellows using GEARS and the procedure-specific scoring scale at the end of the training program was performed by their mentors. However, to standardize the assessment process and minimize bias due to nonblinded assessment, the mentors were informed about and educated in the use of the scoring systems. Fifth, the performance of fellows in RARP video clips was assessed using a new scoring tool. The contents of this scoring criterion were developed and validated on the basis of expert opinion. Sixth, a 3-mo training program may be too short for some fellows to achieve sufficient skills to adequately perform complex parts of the procedure. Finally, there was no specific training or proper pre- and post-training assessment of nontechnical skills.

This study represents the first step towards the definition of an ideal training program for RARP and of criteria for accreditation of surgeons for this procedure. Further studies need to be carried out to address the issues associated with certification and recertification using training curricula.

The concept of surgical training has been evolving in the last decade from the traditional concept of “see one, do one, teach one” towards better defined and standardized methodologies for surgical education based on the development of skill-based curricula [1], [2], [3], [4], and [5]. Furthermore, the development and diffusion of surgical robotic platforms are increasingly supporting the development, use, and validation of simulation-based training methods ranging from bench-top synthetic models, animal, and cadavers to high-fidelity virtual training platforms [6], [7], and [8]. Simulation-based training should be an essential part of surgical training programs to significantly improve the technical and nontechnical skills of trainees, shorten their learning curves for different procedures, and improve surgical safety [9] and [10].

Nevertheless, training for robotic techniques remains mainly unstructured. There has been a recent call by various training bodies for the development of well-organized educational curricula to increase preclinical exposure and of validated assessment tools that allow constructive feedback for performance improvement. These curricula, as well as proficiency-based credential processes, are important for improving patient safety and surgical outcomes in urological surgery [5] and [11].

On the basis of these considerations, the European Association of Urology (EAU) Robotic Urologic Section (ERUS) has designed and developed a structured training program and curriculum in urology that focuses on robot-assisted radical prostatectomy (RARP). The aim of the present study was to assess the feasibility, acceptability, face validity, and educational impact of this curriculum, and to assess improvements in performance and ability to perform RARP after completion of the curriculum.

3. Results

The characteristics and previous robotic experience of the participants are reported in Table 1 . Most participants had minimal or no previous experience of simulation-based training. The median times of involvement as a table assistant and a console surgeon at baseline were 9.5 mo (IQR 5.75–16 mo) and 4 mo (IQR 0–6.5 mo), respectively.

All participants completed the required e-learning module and passed the final test for assessment of theoretical knowledge. All fellows observed and assisted in the recommended number of procedures (>12 cases) during the first 3 wk of the curriculum, participated successfully in all activities during the intensive week of laboratory training, and completed the 8 wk of supervised modular training. The median number of RARPs they were involved in as console surgeons during modular training was 18 (IQR 14–36).

The overall scores obtained by participants for performance of four different dVSS tasks at baseline, during the training program (weeks 4 and 5), and at the end of the curriculum are reported in Figure 2 . For all exercises the overall score significantly increased over the training period (p < 0.001–0.005).

Fig. 2 Progressive improvement in overall scores for different tasks on the da Vinci surgical simulator before, during (weeks 4 and 5), and after completion of the curriculum. * Significant difference compared to overall score before the curriculum (p < 0.05).° Significant difference compared to overall score in week 4 (p < 0.05).

The GEARS scale was used by mentors to evaluate the final RARP performance of fellows ( Fig. 3 A). Good to excellent scores were obtained by 80–100% of trainees for their depth perception (median 5, IQR 4–5), bimanual dexterity (median 4.5, IQR 4–5), efficiency (median 4, IQR 3.75–5), force sensitivity (median 4, IQR 4–5), autonomy (median 4, IQR 3.75–5), and robotic control (median 5, IQR 3.75–5) skills. A procedure-specific scale was used to score the performance of fellows for each RARP surgical step ( Fig. 3 B).

Fig. 3 Mentor assessment of robot-assisted radical prostatectomy performance at the end of the European robot-assisted urologic training curriculum using (A) the GEARS scale and (B) a procedure-specific scale.

Eight trainees (80%) were considered by their mentors able to perform a RARP independently, safely, and efficiently on completion of the curriculum. Three (30%) were considered able to perform a complex RARP independently, safely, and effectively.

The blinded video-based assessment results for RARP steps performed by each fellow and two robotic experts are shown in Table 2 . The fellows achieved an average score that was considered safe (≥10) for all surgical steps. The highest average scores were obtained for bladder detachment and urethrovesical anastomosis. When the scores for all procedural steps were assessed, eight fellows (80%) reached an average score ≥10. The two participants who did not reach an average sufficient score were residents. The robotic experts significantly outperformed the fellows overall (mean score 13.6 vs 11) and for all RARP steps except bladder detachment and endopelvic fascia incision, confirming the construct validity of the assessment ( Fig. 4 ).

Fig. 4 Comparison of robot-assisted radical prostatectomy performance between fellows and experts using a generic dedicated scoring scale (range 4–16).

The results for quantitative surveys completed at the end of curriculum are reported in Figure 5 . All fellows gave an excellent overall evaluation of the training program and felt that the curriculum was very effective in improving their console exposure, their basic robotic skills, and their ability to perform RARP.

Fig. 5 Assessment of the educational impact, face validity, feasibility, and acceptability of the European Association of Urology Robotic Training Curriculum via quantitative surveys.

This is the first study that incorporates and validates different components of a training curriculum for robot-assisted surgery at a multi-institutional level. The study demonstrates that a 12-wk structured training program including theoretical e-learning, laboratory training, and modular training in the operating room is feasible, acceptable, and effective in improving the technical robotic skills and ability of young surgeons with limited previous robotic experience to perform the surgical steps of RARP. The study also demonstrates the face validity of this curriculum.

In the last few years there has been growing interest in the field of surgical education, especially in minimally invasive laparoscopic and robotic surgery [3], [4], [9], and [10]. However, curricula for training in robotic urologic procedures have not yet been standardized and the optimal integration of simulation-based training in surgical training programs is not clearly defined or evidence-based. The definition of curricula for each surgical procedure and their validation and progressive implementation are important for accreditation of surgeons and teams for each specific intervention, with the ultimate aim of improving surgical safety and patient outcomes [5] and [11].

To date, three basic curricula for training and assessment of robotic surgeons have been developed and reported in the literature [3], [4], and [17]. It has been shown that they are valid, feasible, and effective in significantly improving basic robotic surgery skills. However, these curricula do not include modular training in the operating room and they have not been validated for specific procedures.

On the basis of these considerations, the ERUS board members designed and proposed a curriculum for RARP including simulation-based and modular console training with an expert mentor. The curriculum content was finalized in accordance with the expert opinion of robotic surgeons across various regions to ensure content validation [12] . The program is a step forward from existing approaches because it includes all the simulation training modalities available (virtual reality simulation, bench-top models, live animal surgery, and cadaveric procedures) combined with clinical training in the form of a mini-fellowship. Fellowships are actually considered a key component of training for complex urologic procedures such as RARP [18] .

An ideal training program should be feasible, acceptable, valid, and economically sustainable, with an effective educational impact [15] . Our results show that the EAU robotic training curriculum is feasible and acceptable, as all participants were very satisfied with the program and would highly recommend it to other colleagues. All modules of the curriculum were found to be useful, although the fellows subjectively found the virtual reality simulation training, the dry and wet laboratories, and the cadaver training particularly valuable. These data suggest that all these elements should ideally be integrated in training programs, although there are cost, ethical, and regulatory issues to take into account. The centralization of simulation training in an intensive week at a single, fully equipped training centre was well perceived and proved to be effective, as previously demonstrated in other studies [19] .

An effective simulation-based training program represents the ideal background for clinical training in the operating room. The concept of modular training proposed by Stolzenburg et al [14] for laparoscopic radical prostatectomy was adopted in the curriculum for progressive, proficiency-based training of a fellow through steps of increasing levels of difficulty in a surgical procedure. This strategy has the potential to overcome the problems of teaching complex surgical procedures, allowing safe training of surgeons with limited expertise and potentially accelerating their learning curve. The importance of proper mentoring for effective modular training has recently been highlighted [18] .

This pilot study showed that the EAU robotic training curriculum can effectively improve the basic robotic skills of participants, as demonstrated by the significant improvement in overall scores achieved by fellows at the end of the curriculum for all dVSS tasks. The first weeks of simulation training were found to be particularly effective in this respect, potentially allowing participants to optimize the results of subsequent training in the operating room. Importantly, at the end of the curriculum the majority of fellows were able to perform RARP with good or acceptable technical quality, as reflected by scores from mentors and blinded reviews of video-recorded surgeries. The two participants who were not deemed able to perform RARP safely and efficiently by the end of the training program were residents. This may indicate that the curriculum is more likely to be effective for urologists who have already completed their basic training in residency programs.

The curriculum also provided constructive feedback on the performance of fellows for individual procedural steps. Overall, the fellows were able to reach similar performance levels compared to expert surgeons for the easiest RARP steps, such as bladder detachment and endopelvic fascia incision. However, the experts achieved significantly better scores for challenging parts of the procedure, confirming the construct validity of the assessment. Fellows who did not reach sufficient scores for specific surgical steps will need further training before being deemed able to safely perform RARP independently.

Finally, the results indicate that the curriculum has a good educational impact, as well as face validity, defined as the extent to which the program is subjectively viewed as delivering the desired goal. In fact, the majority of the participants felt that the curriculum significantly improved their robotic skills and their ability to perform different RARP steps. However, further comparative studies and, ideally, randomized controlled trials will be needed to assess whether this curriculum is superior to traditional nonstructured training for RARP.

This study has some limitations. First, the number of participants was limited. Second, although the participants had limited previous robotic experience, they were not all completely novice to console surgery, so the results for the training program may be overestimated. The experience level of mentors was not factored in the analysis, but they were all high-volume robotic surgeons at teaching institutions. Third, modular training was not standardized and the console exposure of the participants was variable. Fourth, assessment of the technical skills of the fellows using GEARS and the procedure-specific scoring scale at the end of the training program was performed by their mentors. However, to standardize the assessment process and minimize bias due to nonblinded assessment, the mentors were informed about and educated in the use of the scoring systems. Fifth, the performance of fellows in RARP video clips was assessed using a new scoring tool. The contents of this scoring criterion were developed and validated on the basis of expert opinion. Sixth, a 3-mo training program may be too short for some fellows to achieve sufficient skills to adequately perform complex parts of the procedure. Finally, there was no specific training or proper pre- and post-training assessment of nontechnical skills.

This study represents the first step towards the definition of an ideal training program for RARP and of criteria for accreditation of surgeons for this procedure. Further studies need to be carried out to address the issues associated with certification and recertification using training curricula.

The concept of surgical training has been evolving in the last decade from the traditional concept of “see one, do one, teach one” towards better defined and standardized methodologies for surgical education based on the development of skill-based curricula [1], [2], [3], [4], and [5]. Furthermore, the development and diffusion of surgical robotic platforms are increasingly supporting the development, use, and validation of simulation-based training methods ranging from bench-top synthetic models, animal, and cadavers to high-fidelity virtual training platforms [6], [7], and [8]. Simulation-based training should be an essential part of surgical training programs to significantly improve the technical and nontechnical skills of trainees, shorten their learning curves for different procedures, and improve surgical safety [9] and [10].

Nevertheless, training for robotic techniques remains mainly unstructured. There has been a recent call by various training bodies for the development of well-organized educational curricula to increase preclinical exposure and of validated assessment tools that allow constructive feedback for performance improvement. These curricula, as well as proficiency-based credential processes, are important for improving patient safety and surgical outcomes in urological surgery [5] and [11].

On the basis of these considerations, the European Association of Urology (EAU) Robotic Urologic Section (ERUS) has designed and developed a structured training program and curriculum in urology that focuses on robot-assisted radical prostatectomy (RARP). The aim of the present study was to assess the feasibility, acceptability, face validity, and educational impact of this curriculum, and to assess improvements in performance and ability to perform RARP after completion of the curriculum.

3. Results

The characteristics and previous robotic experience of the participants are reported in Table 1 . Most participants had minimal or no previous experience of simulation-based training. The median times of involvement as a table assistant and a console surgeon at baseline were 9.5 mo (IQR 5.75–16 mo) and 4 mo (IQR 0–6.5 mo), respectively.

All participants completed the required e-learning module and passed the final test for assessment of theoretical knowledge. All fellows observed and assisted in the recommended number of procedures (>12 cases) during the first 3 wk of the curriculum, participated successfully in all activities during the intensive week of laboratory training, and completed the 8 wk of supervised modular training. The median number of RARPs they were involved in as console surgeons during modular training was 18 (IQR 14–36).

The overall scores obtained by participants for performance of four different dVSS tasks at baseline, during the training program (weeks 4 and 5), and at the end of the curriculum are reported in Figure 2 . For all exercises the overall score significantly increased over the training period (p < 0.001–0.005).

Fig. 2 Progressive improvement in overall scores for different tasks on the da Vinci surgical simulator before, during (weeks 4 and 5), and after completion of the curriculum. * Significant difference compared to overall score before the curriculum (p < 0.05).° Significant difference compared to overall score in week 4 (p < 0.05).

The GEARS scale was used by mentors to evaluate the final RARP performance of fellows ( Fig. 3 A). Good to excellent scores were obtained by 80–100% of trainees for their depth perception (median 5, IQR 4–5), bimanual dexterity (median 4.5, IQR 4–5), efficiency (median 4, IQR 3.75–5), force sensitivity (median 4, IQR 4–5), autonomy (median 4, IQR 3.75–5), and robotic control (median 5, IQR 3.75–5) skills. A procedure-specific scale was used to score the performance of fellows for each RARP surgical step ( Fig. 3 B).

Fig. 3 Mentor assessment of robot-assisted radical prostatectomy performance at the end of the European robot-assisted urologic training curriculum using (A) the GEARS scale and (B) a procedure-specific scale.

Eight trainees (80%) were considered by their mentors able to perform a RARP independently, safely, and efficiently on completion of the curriculum. Three (30%) were considered able to perform a complex RARP independently, safely, and effectively.

The blinded video-based assessment results for RARP steps performed by each fellow and two robotic experts are shown in Table 2 . The fellows achieved an average score that was considered safe (≥10) for all surgical steps. The highest average scores were obtained for bladder detachment and urethrovesical anastomosis. When the scores for all procedural steps were assessed, eight fellows (80%) reached an average score ≥10. The two participants who did not reach an average sufficient score were residents. The robotic experts significantly outperformed the fellows overall (mean score 13.6 vs 11) and for all RARP steps except bladder detachment and endopelvic fascia incision, confirming the construct validity of the assessment ( Fig. 4 ).

Fig. 4 Comparison of robot-assisted radical prostatectomy performance between fellows and experts using a generic dedicated scoring scale (range 4–16).

The results for quantitative surveys completed at the end of curriculum are reported in Figure 5 . All fellows gave an excellent overall evaluation of the training program and felt that the curriculum was very effective in improving their console exposure, their basic robotic skills, and their ability to perform RARP.

Fig. 5 Assessment of the educational impact, face validity, feasibility, and acceptability of the European Association of Urology Robotic Training Curriculum via quantitative surveys.

This is the first study that incorporates and validates different components of a training curriculum for robot-assisted surgery at a multi-institutional level. The study demonstrates that a 12-wk structured training program including theoretical e-learning, laboratory training, and modular training in the operating room is feasible, acceptable, and effective in improving the technical robotic skills and ability of young surgeons with limited previous robotic experience to perform the surgical steps of RARP. The study also demonstrates the face validity of this curriculum.

In the last few years there has been growing interest in the field of surgical education, especially in minimally invasive laparoscopic and robotic surgery [3], [4], [9], and [10]. However, curricula for training in robotic urologic procedures have not yet been standardized and the optimal integration of simulation-based training in surgical training programs is not clearly defined or evidence-based. The definition of curricula for each surgical procedure and their validation and progressive implementation are important for accreditation of surgeons and teams for each specific intervention, with the ultimate aim of improving surgical safety and patient outcomes [5] and [11].

To date, three basic curricula for training and assessment of robotic surgeons have been developed and reported in the literature [3], [4], and [17]. It has been shown that they are valid, feasible, and effective in significantly improving basic robotic surgery skills. However, these curricula do not include modular training in the operating room and they have not been validated for specific procedures.

On the basis of these considerations, the ERUS board members designed and proposed a curriculum for RARP including simulation-based and modular console training with an expert mentor. The curriculum content was finalized in accordance with the expert opinion of robotic surgeons across various regions to ensure content validation [12] . The program is a step forward from existing approaches because it includes all the simulation training modalities available (virtual reality simulation, bench-top models, live animal surgery, and cadaveric procedures) combined with clinical training in the form of a mini-fellowship. Fellowships are actually considered a key component of training for complex urologic procedures such as RARP [18] .

An ideal training program should be feasible, acceptable, valid, and economically sustainable, with an effective educational impact [15] . Our results show that the EAU robotic training curriculum is feasible and acceptable, as all participants were very satisfied with the program and would highly recommend it to other colleagues. All modules of the curriculum were found to be useful, although the fellows subjectively found the virtual reality simulation training, the dry and wet laboratories, and the cadaver training particularly valuable. These data suggest that all these elements should ideally be integrated in training programs, although there are cost, ethical, and regulatory issues to take into account. The centralization of simulation training in an intensive week at a single, fully equipped training centre was well perceived and proved to be effective, as previously demonstrated in other studies [19] .

An effective simulation-based training program represents the ideal background for clinical training in the operating room. The concept of modular training proposed by Stolzenburg et al [14] for laparoscopic radical prostatectomy was adopted in the curriculum for progressive, proficiency-based training of a fellow through steps of increasing levels of difficulty in a surgical procedure. This strategy has the potential to overcome the problems of teaching complex surgical procedures, allowing safe training of surgeons with limited expertise and potentially accelerating their learning curve. The importance of proper mentoring for effective modular training has recently been highlighted [18] .

This pilot study showed that the EAU robotic training curriculum can effectively improve the basic robotic skills of participants, as demonstrated by the significant improvement in overall scores achieved by fellows at the end of the curriculum for all dVSS tasks. The first weeks of simulation training were found to be particularly effective in this respect, potentially allowing participants to optimize the results of subsequent training in the operating room. Importantly, at the end of the curriculum the majority of fellows were able to perform RARP with good or acceptable technical quality, as reflected by scores from mentors and blinded reviews of video-recorded surgeries. The two participants who were not deemed able to perform RARP safely and efficiently by the end of the training program were residents. This may indicate that the curriculum is more likely to be effective for urologists who have already completed their basic training in residency programs.

The curriculum also provided constructive feedback on the performance of fellows for individual procedural steps. Overall, the fellows were able to reach similar performance levels compared to expert surgeons for the easiest RARP steps, such as bladder detachment and endopelvic fascia incision. However, the experts achieved significantly better scores for challenging parts of the procedure, confirming the construct validity of the assessment. Fellows who did not reach sufficient scores for specific surgical steps will need further training before being deemed able to safely perform RARP independently.

Finally, the results indicate that the curriculum has a good educational impact, as well as face validity, defined as the extent to which the program is subjectively viewed as delivering the desired goal. In fact, the majority of the participants felt that the curriculum significantly improved their robotic skills and their ability to perform different RARP steps. However, further comparative studies and, ideally, randomized controlled trials will be needed to assess whether this curriculum is superior to traditional nonstructured training for RARP.

This study has some limitations. First, the number of participants was limited. Second, although the participants had limited previous robotic experience, they were not all completely novice to console surgery, so the results for the training program may be overestimated. The experience level of mentors was not factored in the analysis, but they were all high-volume robotic surgeons at teaching institutions. Third, modular training was not standardized and the console exposure of the participants was variable. Fourth, assessment of the technical skills of the fellows using GEARS and the procedure-specific scoring scale at the end of the training program was performed by their mentors. However, to standardize the assessment process and minimize bias due to nonblinded assessment, the mentors were informed about and educated in the use of the scoring systems. Fifth, the performance of fellows in RARP video clips was assessed using a new scoring tool. The contents of this scoring criterion were developed and validated on the basis of expert opinion. Sixth, a 3-mo training program may be too short for some fellows to achieve sufficient skills to adequately perform complex parts of the procedure. Finally, there was no specific training or proper pre- and post-training assessment of nontechnical skills.

This study represents the first step towards the definition of an ideal training program for RARP and of criteria for accreditation of surgeons for this procedure. Further studies need to be carried out to address the issues associated with certification and recertification using training curricula.

The concept of surgical training has been evolving in the last decade from the traditional concept of “see one, do one, teach one” towards better defined and standardized methodologies for surgical education based on the development of skill-based curricula [1], [2], [3], [4], and [5]. Furthermore, the development and diffusion of surgical robotic platforms are increasingly supporting the development, use, and validation of simulation-based training methods ranging from bench-top synthetic models, animal, and cadavers to high-fidelity virtual training platforms [6], [7], and [8]. Simulation-based training should be an essential part of surgical training programs to significantly improve the technical and nontechnical skills of trainees, shorten their learning curves for different procedures, and improve surgical safety [9] and [10].

Nevertheless, training for robotic techniques remains mainly unstructured. There has been a recent call by various training bodies for the development of well-organized educational curricula to increase preclinical exposure and of validated assessment tools that allow constructive feedback for performance improvement. These curricula, as well as proficiency-based credential processes, are important for improving patient safety and surgical outcomes in urological surgery [5] and [11].

On the basis of these considerations, the European Association of Urology (EAU) Robotic Urologic Section (ERUS) has designed and developed a structured training program and curriculum in urology that focuses on robot-assisted radical prostatectomy (RARP). The aim of the present study was to assess the feasibility, acceptability, face validity, and educational impact of this curriculum, and to assess improvements in performance and ability to perform RARP after completion of the curriculum.

3. Results

The characteristics and previous robotic experience of the participants are reported in Table 1 . Most participants had minimal or no previous experience of simulation-based training. The median times of involvement as a table assistant and a console surgeon at baseline were 9.5 mo (IQR 5.75–16 mo) and 4 mo (IQR 0–6.5 mo), respectively.

All participants completed the required e-learning module and passed the final test for assessment of theoretical knowledge. All fellows observed and assisted in the recommended number of procedures (>12 cases) during the first 3 wk of the curriculum, participated successfully in all activities during the intensive week of laboratory training, and completed the 8 wk of supervised modular training. The median number of RARPs they were involved in as console surgeons during modular training was 18 (IQR 14–36).

The overall scores obtained by participants for performance of four different dVSS tasks at baseline, during the training program (weeks 4 and 5), and at the end of the curriculum are reported in Figure 2 . For all exercises the overall score significantly increased over the training period (p < 0.001–0.005).

Fig. 2 Progressive improvement in overall scores for different tasks on the da Vinci surgical simulator before, during (weeks 4 and 5), and after completion of the curriculum. * Significant difference compared to overall score before the curriculum (p < 0.05).° Significant difference compared to overall score in week 4 (p < 0.05).

The GEARS scale was used by mentors to evaluate the final RARP performance of fellows ( Fig. 3 A). Good to excellent scores were obtained by 80–100% of trainees for their depth perception (median 5, IQR 4–5), bimanual dexterity (median 4.5, IQR 4–5), efficiency (median 4, IQR 3.75–5), force sensitivity (median 4, IQR 4–5), autonomy (median 4, IQR 3.75–5), and robotic control (median 5, IQR 3.75–5) skills. A procedure-specific scale was used to score the performance of fellows for each RARP surgical step ( Fig. 3 B).

Fig. 3 Mentor assessment of robot-assisted radical prostatectomy performance at the end of the European robot-assisted urologic training curriculum using (A) the GEARS scale and (B) a procedure-specific scale.

Eight trainees (80%) were considered by their mentors able to perform a RARP independently, safely, and efficiently on completion of the curriculum. Three (30%) were considered able to perform a complex RARP independently, safely, and effectively.

The blinded video-based assessment results for RARP steps performed by each fellow and two robotic experts are shown in Table 2 . The fellows achieved an average score that was considered safe (≥10) for all surgical steps. The highest average scores were obtained for bladder detachment and urethrovesical anastomosis. When the scores for all procedural steps were assessed, eight fellows (80%) reached an average score ≥10. The two participants who did not reach an average sufficient score were residents. The robotic experts significantly outperformed the fellows overall (mean score 13.6 vs 11) and for all RARP steps except bladder detachment and endopelvic fascia incision, confirming the construct validity of the assessment ( Fig. 4 ).

Fig. 4 Comparison of robot-assisted radical prostatectomy performance between fellows and experts using a generic dedicated scoring scale (range 4–16).

The results for quantitative surveys completed at the end of curriculum are reported in Figure 5 . All fellows gave an excellent overall evaluation of the training program and felt that the curriculum was very effective in improving their console exposure, their basic robotic skills, and their ability to perform RARP.

Fig. 5 Assessment of the educational impact, face validity, feasibility, and acceptability of the European Association of Urology Robotic Training Curriculum via quantitative surveys.

This is the first study that incorporates and validates different components of a training curriculum for robot-assisted surgery at a multi-institutional level. The study demonstrates that a 12-wk structured training program including theoretical e-learning, laboratory training, and modular training in the operating room is feasible, acceptable, and effective in improving the technical robotic skills and ability of young surgeons with limited previous robotic experience to perform the surgical steps of RARP. The study also demonstrates the face validity of this curriculum.

In the last few years there has been growing interest in the field of surgical education, especially in minimally invasive laparoscopic and robotic surgery [3], [4], [9], and [10]. However, curricula for training in robotic urologic procedures have not yet been standardized and the optimal integration of simulation-based training in surgical training programs is not clearly defined or evidence-based. The definition of curricula for each surgical procedure and their validation and progressive implementation are important for accreditation of surgeons and teams for each specific intervention, with the ultimate aim of improving surgical safety and patient outcomes [5] and [11].

To date, three basic curricula for training and assessment of robotic surgeons have been developed and reported in the literature [3], [4], and [17]. It has been shown that they are valid, feasible, and effective in significantly improving basic robotic surgery skills. However, these curricula do not include modular training in the operating room and they have not been validated for specific procedures.

On the basis of these considerations, the ERUS board members designed and proposed a curriculum for RARP including simulation-based and modular console training with an expert mentor. The curriculum content was finalized in accordance with the expert opinion of robotic surgeons across various regions to ensure content validation [12] . The program is a step forward from existing approaches because it includes all the simulation training modalities available (virtual reality simulation, bench-top models, live animal surgery, and cadaveric procedures) combined with clinical training in the form of a mini-fellowship. Fellowships are actually considered a key component of training for complex urologic procedures such as RARP [18] .

An ideal training program should be feasible, acceptable, valid, and economically sustainable, with an effective educational impact [15] . Our results show that the EAU robotic training curriculum is feasible and acceptable, as all participants were very satisfied with the program and would highly recommend it to other colleagues. All modules of the curriculum were found to be useful, although the fellows subjectively found the virtual reality simulation training, the dry and wet laboratories, and the cadaver training particularly valuable. These data suggest that all these elements should ideally be integrated in training programs, although there are cost, ethical, and regulatory issues to take into account. The centralization of simulation training in an intensive week at a single, fully equipped training centre was well perceived and proved to be effective, as previously demonstrated in other studies [19] .

An effective simulation-based training program represents the ideal background for clinical training in the operating room. The concept of modular training proposed by Stolzenburg et al [14] for laparoscopic radical prostatectomy was adopted in the curriculum for progressive, proficiency-based training of a fellow through steps of increasing levels of difficulty in a surgical procedure. This strategy has the potential to overcome the problems of teaching complex surgical procedures, allowing safe training of surgeons with limited expertise and potentially accelerating their learning curve. The importance of proper mentoring for effective modular training has recently been highlighted [18] .

This pilot study showed that the EAU robotic training curriculum can effectively improve the basic robotic skills of participants, as demonstrated by the significant improvement in overall scores achieved by fellows at the end of the curriculum for all dVSS tasks. The first weeks of simulation training were found to be particularly effective in this respect, potentially allowing participants to optimize the results of subsequent training in the operating room. Importantly, at the end of the curriculum the majority of fellows were able to perform RARP with good or acceptable technical quality, as reflected by scores from mentors and blinded reviews of video-recorded surgeries. The two participants who were not deemed able to perform RARP safely and efficiently by the end of the training program were residents. This may indicate that the curriculum is more likely to be effective for urologists who have already completed their basic training in residency programs.

The curriculum also provided constructive feedback on the performance of fellows for individual procedural steps. Overall, the fellows were able to reach similar performance levels compared to expert surgeons for the easiest RARP steps, such as bladder detachment and endopelvic fascia incision. However, the experts achieved significantly better scores for challenging parts of the procedure, confirming the construct validity of the assessment. Fellows who did not reach sufficient scores for specific surgical steps will need further training before being deemed able to safely perform RARP independently.

Finally, the results indicate that the curriculum has a good educational impact, as well as face validity, defined as the extent to which the program is subjectively viewed as delivering the desired goal. In fact, the majority of the participants felt that the curriculum significantly improved their robotic skills and their ability to perform different RARP steps. However, further comparative studies and, ideally, randomized controlled trials will be needed to assess whether this curriculum is superior to traditional nonstructured training for RARP.

This study has some limitations. First, the number of participants was limited. Second, although the participants had limited previous robotic experience, they were not all completely novice to console surgery, so the results for the training program may be overestimated. The experience level of mentors was not factored in the analysis, but they were all high-volume robotic surgeons at teaching institutions. Third, modular training was not standardized and the console exposure of the participants was variable. Fourth, assessment of the technical skills of the fellows using GEARS and the procedure-specific scoring scale at the end of the training program was performed by their mentors. However, to standardize the assessment process and minimize bias due to nonblinded assessment, the mentors were informed about and educated in the use of the scoring systems. Fifth, the performance of fellows in RARP video clips was assessed using a new scoring tool. The contents of this scoring criterion were developed and validated on the basis of expert opinion. Sixth, a 3-mo training program may be too short for some fellows to achieve sufficient skills to adequately perform complex parts of the procedure. Finally, there was no specific training or proper pre- and post-training assessment of nontechnical skills.

This study represents the first step towards the definition of an ideal training program for RARP and of criteria for accreditation of surgeons for this procedure. Further studies need to be carried out to address the issues associated with certification and recertification using training curricula.

The concept of surgical training has been evolving in the last decade from the traditional concept of “see one, do one, teach one” towards better defined and standardized methodologies for surgical education based on the development of skill-based curricula [1], [2], [3], [4], and [5]. Furthermore, the development and diffusion of surgical robotic platforms are increasingly supporting the development, use, and validation of simulation-based training methods ranging from bench-top synthetic models, animal, and cadavers to high-fidelity virtual training platforms [6], [7], and [8]. Simulation-based training should be an essential part of surgical training programs to significantly improve the technical and nontechnical skills of trainees, shorten their learning curves for different procedures, and improve surgical safety [9] and [10].

Nevertheless, training for robotic techniques remains mainly unstructured. There has been a recent call by various training bodies for the development of well-organized educational curricula to increase preclinical exposure and of validated assessment tools that allow constructive feedback for performance improvement. These curricula, as well as proficiency-based credential processes, are important for improving patient safety and surgical outcomes in urological surgery [5] and [11].

On the basis of these considerations, the European Association of Urology (EAU) Robotic Urologic Section (ERUS) has designed and developed a structured training program and curriculum in urology that focuses on robot-assisted radical prostatectomy (RARP). The aim of the present study was to assess the feasibility, acceptability, face validity, and educational impact of this curriculum, and to assess improvements in performance and ability to perform RARP after completion of the curriculum.

3. Results

The characteristics and previous robotic experience of the participants are reported in Table 1 . Most participants had minimal or no previous experience of simulation-based training. The median times of involvement as a table assistant and a console surgeon at baseline were 9.5 mo (IQR 5.75–16 mo) and 4 mo (IQR 0–6.5 mo), respectively.

All participants completed the required e-learning module and passed the final test for assessment of theoretical knowledge. All fellows observed and assisted in the recommended number of procedures (>12 cases) during the first 3 wk of the curriculum, participated successfully in all activities during the intensive week of laboratory training, and completed the 8 wk of supervised modular training. The median number of RARPs they were involved in as console surgeons during modular training was 18 (IQR 14–36).

The overall scores obtained by participants for performance of four different dVSS tasks at baseline, during the training program (weeks 4 and 5), and at the end of the curriculum are reported in Figure 2 . For all exercises the overall score significantly increased over the training period (p < 0.001–0.005).

Fig. 2 Progressive improvement in overall scores for different tasks on the da Vinci surgical simulator before, during (weeks 4 and 5), and after completion of the curriculum. * Significant difference compared to overall score before the curriculum (p < 0.05).° Significant difference compared to overall score in week 4 (p < 0.05).

The GEARS scale was used by mentors to evaluate the final RARP performance of fellows ( Fig. 3 A). Good to excellent scores were obtained by 80–100% of trainees for their depth perception (median 5, IQR 4–5), bimanual dexterity (median 4.5, IQR 4–5), efficiency (median 4, IQR 3.75–5), force sensitivity (median 4, IQR 4–5), autonomy (median 4, IQR 3.75–5), and robotic control (median 5, IQR 3.75–5) skills. A procedure-specific scale was used to score the performance of fellows for each RARP surgical step ( Fig. 3 B).

Fig. 3 Mentor assessment of robot-assisted radical prostatectomy performance at the end of the European robot-assisted urologic training curriculum using (A) the GEARS scale and (B) a procedure-specific scale.

Eight trainees (80%) were considered by their mentors able to perform a RARP independently, safely, and efficiently on completion of the curriculum. Three (30%) were considered able to perform a complex RARP independently, safely, and effectively.

The blinded video-based assessment results for RARP steps performed by each fellow and two robotic experts are shown in Table 2 . The fellows achieved an average score that was considered safe (≥10) for all surgical steps. The highest average scores were obtained for bladder detachment and urethrovesical anastomosis. When the scores for all procedural steps were assessed, eight fellows (80%) reached an average score ≥10. The two participants who did not reach an average sufficient score were residents. The robotic experts significantly outperformed the fellows overall (mean score 13.6 vs 11) and for all RARP steps except bladder detachment and endopelvic fascia incision, confirming the construct validity of the assessment ( Fig. 4 ).

Fig. 4 Comparison of robot-assisted radical prostatectomy performance between fellows and experts using a generic dedicated scoring scale (range 4–16).

The results for quantitative surveys completed at the end of curriculum are reported in Figure 5 . All fellows gave an excellent overall evaluation of the training program and felt that the curriculum was very effective in improving their console exposure, their basic robotic skills, and their ability to perform RARP.

Fig. 5 Assessment of the educational impact, face validity, feasibility, and acceptability of the European Association of Urology Robotic Training Curriculum via quantitative surveys.

This is the first study that incorporates and validates different components of a training curriculum for robot-assisted surgery at a multi-institutional level. The study demonstrates that a 12-wk structured training program including theoretical e-learning, laboratory training, and modular training in the operating room is feasible, acceptable, and effective in improving the technical robotic skills and ability of young surgeons with limited previous robotic experience to perform the surgical steps of RARP. The study also demonstrates the face validity of this curriculum.

In the last few years there has been growing interest in the field of surgical education, especially in minimally invasive laparoscopic and robotic surgery [3], [4], [9], and [10]. However, curricula for training in robotic urologic procedures have not yet been standardized and the optimal integration of simulation-based training in surgical training programs is not clearly defined or evidence-based. The definition of curricula for each surgical procedure and their validation and progressive implementation are important for accreditation of surgeons and teams for each specific intervention, with the ultimate aim of improving surgical safety and patient outcomes [5] and [11].

To date, three basic curricula for training and assessment of robotic surgeons have been developed and reported in the literature [3], [4], and [17]. It has been shown that they are valid, feasible, and effective in significantly improving basic robotic surgery skills. However, these curricula do not include modular training in the operating room and they have not been validated for specific procedures.

On the basis of these considerations, the ERUS board members designed and proposed a curriculum for RARP including simulation-based and modular console training with an expert mentor. The curriculum content was finalized in accordance with the expert opinion of robotic surgeons across various regions to ensure content validation [12] . The program is a step forward from existing approaches because it includes all the simulation training modalities available (virtual reality simulation, bench-top models, live animal surgery, and cadaveric procedures) combined with clinical training in the form of a mini-fellowship. Fellowships are actually considered a key component of training for complex urologic procedures such as RARP [18] .

An ideal training program should be feasible, acceptable, valid, and economically sustainable, with an effective educational impact [15] . Our results show that the EAU robotic training curriculum is feasible and acceptable, as all participants were very satisfied with the program and would highly recommend it to other colleagues. All modules of the curriculum were found to be useful, although the fellows subjectively found the virtual reality simulation training, the dry and wet laboratories, and the cadaver training particularly valuable. These data suggest that all these elements should ideally be integrated in training programs, although there are cost, ethical, and regulatory issues to take into account. The centralization of simulation training in an intensive week at a single, fully equipped training centre was well perceived and proved to be effective, as previously demonstrated in other studies [19] .

An effective simulation-based training program represents the ideal background for clinical training in the operating room. The concept of modular training proposed by Stolzenburg et al [14] for laparoscopic radical prostatectomy was adopted in the curriculum for progressive, proficiency-based training of a fellow through steps of increasing levels of difficulty in a surgical procedure. This strategy has the potential to overcome the problems of teaching complex surgical procedures, allowing safe training of surgeons with limited expertise and potentially accelerating their learning curve. The importance of proper mentoring for effective modular training has recently been highlighted [18] .

This pilot study showed that the EAU robotic training curriculum can effectively improve the basic robotic skills of participants, as demonstrated by the significant improvement in overall scores achieved by fellows at the end of the curriculum for all dVSS tasks. The first weeks of simulation training were found to be particularly effective in this respect, potentially allowing participants to optimize the results of subsequent training in the operating room. Importantly, at the end of the curriculum the majority of fellows were able to perform RARP with good or acceptable technical quality, as reflected by scores from mentors and blinded reviews of video-recorded surgeries. The two participants who were not deemed able to perform RARP safely and efficiently by the end of the training program were residents. This may indicate that the curriculum is more likely to be effective for urologists who have already completed their basic training in residency programs.

The curriculum also provided constructive feedback on the performance of fellows for individual procedural steps. Overall, the fellows were able to reach similar performance levels compared to expert surgeons for the easiest RARP steps, such as bladder detachment and endopelvic fascia incision. However, the experts achieved significantly better scores for challenging parts of the procedure, confirming the construct validity of the assessment. Fellows who did not reach sufficient scores for specific surgical steps will need further training before being deemed able to safely perform RARP independently.

Finally, the results indicate that the curriculum has a good educational impact, as well as face validity, defined as the extent to which the program is subjectively viewed as delivering the desired goal. In fact, the majority of the participants felt that the curriculum significantly improved their robotic skills and their ability to perform different RARP steps. However, further comparative studies and, ideally, randomized controlled trials will be needed to assess whether this curriculum is superior to traditional nonstructured training for RARP.

This study has some limitations. First, the number of participants was limited. Second, although the participants had limited previous robotic experience, they were not all completely novice to console surgery, so the results for the training program may be overestimated. The experience level of mentors was not factored in the analysis, but they were all high-volume robotic surgeons at teaching institutions. Third, modular training was not standardized and the console exposure of the participants was variable. Fourth, assessment of the technical skills of the fellows using GEARS and the procedure-specific scoring scale at the end of the training program was performed by their mentors. However, to standardize the assessment process and minimize bias due to nonblinded assessment, the mentors were informed about and educated in the use of the scoring systems. Fifth, the performance of fellows in RARP video clips was assessed using a new scoring tool. The contents of this scoring criterion were developed and validated on the basis of expert opinion. Sixth, a 3-mo training program may be too short for some fellows to achieve sufficient skills to adequately perform complex parts of the procedure. Finally, there was no specific training or proper pre- and post-training assessment of nontechnical skills.

This study represents the first step towards the definition of an ideal training program for RARP and of criteria for accreditation of surgeons for this procedure. Further studies need to be carried out to address the issues associated with certification and recertification using training curricula.

The concept of surgical training has been evolving in the last decade from the traditional concept of “see one, do one, teach one” towards better defined and standardized methodologies for surgical education based on the development of skill-based curricula [1], [2], [3], [4], and [5]. Furthermore, the development and diffusion of surgical robotic platforms are increasingly supporting the development, use, and validation of simulation-based training methods ranging from bench-top synthetic models, animal, and cadavers to high-fidelity virtual training platforms [6], [7], and [8]. Simulation-based training should be an essential part of surgical training programs to significantly improve the technical and nontechnical skills of trainees, shorten their learning curves for different procedures, and improve surgical safety [9] and [10].

Nevertheless, training for robotic techniques remains mainly unstructured. There has been a recent call by various training bodies for the development of well-organized educational curricula to increase preclinical exposure and of validated assessment tools that allow constructive feedback for performance improvement. These curricula, as well as proficiency-based credential processes, are important for improving patient safety and surgical outcomes in urological surgery [5] and [11].

On the basis of these considerations, the European Association of Urology (EAU) Robotic Urologic Section (ERUS) has designed and developed a structured training program and curriculum in urology that focuses on robot-assisted radical prostatectomy (RARP). The aim of the present study was to assess the feasibility, acceptability, face validity, and educational impact of this curriculum, and to assess improvements in performance and ability to perform RARP after completion of the curriculum.

3. Results

The characteristics and previous robotic experience of the participants are reported in Table 1 . Most participants had minimal or no previous experience of simulation-based training. The median times of involvement as a table assistant and a console surgeon at baseline were 9.5 mo (IQR 5.75–16 mo) and 4 mo (IQR 0–6.5 mo), respectively.

All participants completed the required e-learning module and passed the final test for assessment of theoretical knowledge. All fellows observed and assisted in the recommended number of procedures (>12 cases) during the first 3 wk of the curriculum, participated successfully in all activities during the intensive week of laboratory training, and completed the 8 wk of supervised modular training. The median number of RARPs they were involved in as console surgeons during modular training was 18 (IQR 14–36).

The overall scores obtained by participants for performance of four different dVSS tasks at baseline, during the training program (weeks 4 and 5), and at the end of the curriculum are reported in Figure 2 . For all exercises the overall score significantly increased over the training period (p < 0.001–0.005).

Fig. 2 Progressive improvement in overall scores for different tasks on the da Vinci surgical simulator before, during (weeks 4 and 5), and after completion of the curriculum. * Significant difference compared to overall score before the curriculum (p < 0.05).° Significant difference compared to overall score in week 4 (p < 0.05).

The GEARS scale was used by mentors to evaluate the final RARP performance of fellows ( Fig. 3 A). Good to excellent scores were obtained by 80–100% of trainees for their depth perception (median 5, IQR 4–5), bimanual dexterity (median 4.5, IQR 4–5), efficiency (median 4, IQR 3.75–5), force sensitivity (median 4, IQR 4–5), autonomy (median 4, IQR 3.75–5), and robotic control (median 5, IQR 3.75–5) skills. A procedure-specific scale was used to score the performance of fellows for each RARP surgical step ( Fig. 3 B).

Fig. 3 Mentor assessment of robot-assisted radical prostatectomy performance at the end of the European robot-assisted urologic training curriculum using (A) the GEARS scale and (B) a procedure-specific scale.

Eight trainees (80%) were considered by their mentors able to perform a RARP independently, safely, and efficiently on completion of the curriculum. Three (30%) were considered able to perform a complex RARP independently, safely, and effectively.

The blinded video-based assessment results for RARP steps performed by each fellow and two robotic experts are shown in Table 2 . The fellows achieved an average score that was considered safe (≥10) for all surgical steps. The highest average scores were obtained for bladder detachment and urethrovesical anastomosis. When the scores for all procedural steps were assessed, eight fellows (80%) reached an average score ≥10. The two participants who did not reach an average sufficient score were residents. The robotic experts significantly outperformed the fellows overall (mean score 13.6 vs 11) and for all RARP steps except bladder detachment and endopelvic fascia incision, confirming the construct validity of the assessment ( Fig. 4 ).

Fig. 4 Comparison of robot-assisted radical prostatectomy performance between fellows and experts using a generic dedicated scoring scale (range 4–16).

The results for quantitative surveys completed at the end of curriculum are reported in Figure 5 . All fellows gave an excellent overall evaluation of the training program and felt that the curriculum was very effective in improving their console exposure, their basic robotic skills, and their ability to perform RARP.

Fig. 5 Assessment of the educational impact, face validity, feasibility, and acceptability of the European Association of Urology Robotic Training Curriculum via quantitative surveys.

This is the first study that incorporates and validates different components of a training curriculum for robot-assisted surgery at a multi-institutional level. The study demonstrates that a 12-wk structured training program including theoretical e-learning, laboratory training, and modular training in the operating room is feasible, acceptable, and effective in improving the technical robotic skills and ability of young surgeons with limited previous robotic experience to perform the surgical steps of RARP. The study also demonstrates the face validity of this curriculum.

In the last few years there has been growing interest in the field of surgical education, especially in minimally invasive laparoscopic and robotic surgery [3], [4], [9], and [10]. However, curricula for training in robotic urologic procedures have not yet been standardized and the optimal integration of simulation-based training in surgical training programs is not clearly defined or evidence-based. The definition of curricula for each surgical procedure and their validation and progressive implementation are important for accreditation of surgeons and teams for each specific intervention, with the ultimate aim of improving surgical safety and patient outcomes [5] and [11].

To date, three basic curricula for training and assessment of robotic surgeons have been developed and reported in the literature [3], [4], and [17]. It has been shown that they are valid, feasible, and effective in significantly improving basic robotic surgery skills. However, these curricula do not include modular training in the operating room and they have not been validated for specific procedures.

On the basis of these considerations, the ERUS board members designed and proposed a curriculum for RARP including simulation-based and modular console training with an expert mentor. The curriculum content was finalized in accordance with the expert opinion of robotic surgeons across various regions to ensure content validation [12] . The program is a step forward from existing approaches because it includes all the simulation training modalities available (virtual reality simulation, bench-top models, live animal surgery, and cadaveric procedures) combined with clinical training in the form of a mini-fellowship. Fellowships are actually considered a key component of training for complex urologic procedures such as RARP [18] .

An ideal training program should be feasible, acceptable, valid, and economically sustainable, with an effective educational impact [15] . Our results show that the EAU robotic training curriculum is feasible and acceptable, as all participants were very satisfied with the program and would highly recommend it to other colleagues. All modules of the curriculum were found to be useful, although the fellows subjectively found the virtual reality simulation training, the dry and wet laboratories, and the cadaver training particularly valuable. These data suggest that all these elements should ideally be integrated in training programs, although there are cost, ethical, and regulatory issues to take into account. The centralization of simulation training in an intensive week at a single, fully equipped training centre was well perceived and proved to be effective, as previously demonstrated in other studies [19] .

An effective simulation-based training program represents the ideal background for clinical training in the operating room. The concept of modular training proposed by Stolzenburg et al [14] for laparoscopic radical prostatectomy was adopted in the curriculum for progressive, proficiency-based training of a fellow through steps of increasing levels of difficulty in a surgical procedure. This strategy has the potential to overcome the problems of teaching complex surgical procedures, allowing safe training of surgeons with limited expertise and potentially accelerating their learning curve. The importance of proper mentoring for effective modular training has recently been highlighted [18] .

This pilot study showed that the EAU robotic training curriculum can effectively improve the basic robotic skills of participants, as demonstrated by the significant improvement in overall scores achieved by fellows at the end of the curriculum for all dVSS tasks. The first weeks of simulation training were found to be particularly effective in this respect, potentially allowing participants to optimize the results of subsequent training in the operating room. Importantly, at the end of the curriculum the majority of fellows were able to perform RARP with good or acceptable technical quality, as reflected by scores from mentors and blinded reviews of video-recorded surgeries. The two participants who were not deemed able to perform RARP safely and efficiently by the end of the training program were residents. This may indicate that the curriculum is more likely to be effective for urologists who have already completed their basic training in residency programs.

The curriculum also provided constructive feedback on the performance of fellows for individual procedural steps. Overall, the fellows were able to reach similar performance levels compared to expert surgeons for the easiest RARP steps, such as bladder detachment and endopelvic fascia incision. However, the experts achieved significantly better scores for challenging parts of the procedure, confirming the construct validity of the assessment. Fellows who did not reach sufficient scores for specific surgical steps will need further training before being deemed able to safely perform RARP independently.

Finally, the results indicate that the curriculum has a good educational impact, as well as face validity, defined as the extent to which the program is subjectively viewed as delivering the desired goal. In fact, the majority of the participants felt that the curriculum significantly improved their robotic skills and their ability to perform different RARP steps. However, further comparative studies and, ideally, randomized controlled trials will be needed to assess whether this curriculum is superior to traditional nonstructured training for RARP.

This study has some limitations. First, the number of participants was limited. Second, although the participants had limited previous robotic experience, they were not all completely novice to console surgery, so the results for the training program may be overestimated. The experience level of mentors was not factored in the analysis, but they were all high-volume robotic surgeons at teaching institutions. Third, modular training was not standardized and the console exposure of the participants was variable. Fourth, assessment of the technical skills of the fellows using GEARS and the procedure-specific scoring scale at the end of the training program was performed by their mentors. However, to standardize the assessment process and minimize bias due to nonblinded assessment, the mentors were informed about and educated in the use of the scoring systems. Fifth, the performance of fellows in RARP video clips was assessed using a new scoring tool. The contents of this scoring criterion were developed and validated on the basis of expert opinion. Sixth, a 3-mo training program may be too short for some fellows to achieve sufficient skills to adequately perform complex parts of the procedure. Finally, there was no specific training or proper pre- and post-training assessment of nontechnical skills.

This study represents the first step towards the definition of an ideal training program for RARP and of criteria for accreditation of surgeons for this procedure. Further studies need to be carried out to address the issues associated with certification and recertification using training curricula.

The concept of surgical training has been evolving in the last decade from the traditional concept of “see one, do one, teach one” towards better defined and standardized methodologies for surgical education based on the development of skill-based curricula [1], [2], [3], [4], and [5]. Furthermore, the development and diffusion of surgical robotic platforms are increasingly supporting the development, use, and validation of simulation-based training methods ranging from bench-top synthetic models, animal, and cadavers to high-fidelity virtual training platforms [6], [7], and [8]. Simulation-based training should be an essential part of surgical training programs to significantly improve the technical and nontechnical skills of trainees, shorten their learning curves for different procedures, and improve surgical safety [9] and [10].

Nevertheless, training for robotic techniques remains mainly unstructured. There has been a recent call by various training bodies for the development of well-organized educational curricula to increase preclinical exposure and of validated assessment tools that allow constructive feedback for performance improvement. These curricula, as well as proficiency-based credential processes, are important for improving patient safety and surgical outcomes in urological surgery [5] and [11].

On the basis of these considerations, the European Association of Urology (EAU) Robotic Urologic Section (ERUS) has designed and developed a structured training program and curriculum in urology that focuses on robot-assisted radical prostatectomy (RARP). The aim of the present study was to assess the feasibility, acceptability, face validity, and educational impact of this curriculum, and to assess improvements in performance and ability to perform RARP after completion of the curriculum.

3. Results

The characteristics and previous robotic experience of the participants are reported in Table 1 . Most participants had minimal or no previous experience of simulation-based training. The median times of involvement as a table assistant and a console surgeon at baseline were 9.5 mo (IQR 5.75–16 mo) and 4 mo (IQR 0–6.5 mo), respectively.

All participants completed the required e-learning module and passed the final test for assessment of theoretical knowledge. All fellows observed and assisted in the recommended number of procedures (>12 cases) during the first 3 wk of the curriculum, participated successfully in all activities during the intensive week of laboratory training, and completed the 8 wk of supervised modular training. The median number of RARPs they were involved in as console surgeons during modular training was 18 (IQR 14–36).

The overall scores obtained by participants for performance of four different dVSS tasks at baseline, during the training program (weeks 4 and 5), and at the end of the curriculum are reported in Figure 2 . For all exercises the overall score significantly increased over the training period (p < 0.001–0.005).

Fig. 2 Progressive improvement in overall scores for different tasks on the da Vinci surgical simulator before, during (weeks 4 and 5), and after completion of the curriculum. * Significant difference compared to overall score before the curriculum (p < 0.05).° Significant difference compared to overall score in week 4 (p < 0.05).

The GEARS scale was used by mentors to evaluate the final RARP performance of fellows ( Fig. 3 A). Good to excellent scores were obtained by 80–100% of trainees for their depth perception (median 5, IQR 4–5), bimanual dexterity (median 4.5, IQR 4–5), efficiency (median 4, IQR 3.75–5), force sensitivity (median 4, IQR 4–5), autonomy (median 4, IQR 3.75–5), and robotic control (median 5, IQR 3.75–5) skills. A procedure-specific scale was used to score the performance of fellows for each RARP surgical step ( Fig. 3 B).

Fig. 3 Mentor assessment of robot-assisted radical prostatectomy performance at the end of the European robot-assisted urologic training curriculum using (A) the GEARS scale and (B) a procedure-specific scale.

Eight trainees (80%) were considered by their mentors able to perform a RARP independently, safely, and efficiently on completion of the curriculum. Three (30%) were considered able to perform a complex RARP independently, safely, and effectively.

The blinded video-based assessment results for RARP steps performed by each fellow and two robotic experts are shown in Table 2 . The fellows achieved an average score that was considered safe (≥10) for all surgical steps. The highest average scores were obtained for bladder detachment and urethrovesical anastomosis. When the scores for all procedural steps were assessed, eight fellows (80%) reached an average score ≥10. The two participants who did not reach an average sufficient score were residents. The robotic experts significantly outperformed the fellows overall (mean score 13.6 vs 11) and for all RARP steps except bladder detachment and endopelvic fascia incision, confirming the construct validity of the assessment ( Fig. 4 ).

Fig. 4 Comparison of robot-assisted radical prostatectomy performance between fellows and experts using a generic dedicated scoring scale (range 4–16).

The results for quantitative surveys completed at the end of curriculum are reported in Figure 5 . All fellows gave an excellent overall evaluation of the training program and felt that the curriculum was very effective in improving their console exposure, their basic robotic skills, and their ability to perform RARP.

Fig. 5 Assessment of the educational impact, face validity, feasibility, and acceptability of the European Association of Urology Robotic Training Curriculum via quantitative surveys.

This is the first study that incorporates and validates different components of a training curriculum for robot-assisted surgery at a multi-institutional level. The study demonstrates that a 12-wk structured training program including theoretical e-learning, laboratory training, and modular training in the operating room is feasible, acceptable, and effective in improving the technical robotic skills and ability of young surgeons with limited previous robotic experience to perform the surgical steps of RARP. The study also demonstrates the face validity of this curriculum.

In the last few years there has been growing interest in the field of surgical education, especially in minimally invasive laparoscopic and robotic surgery [3], [4], [9], and [10]. However, curricula for training in robotic urologic procedures have not yet been standardized and the optimal integration of simulation-based training in surgical training programs is not clearly defined or evidence-based. The definition of curricula for each surgical procedure and their validation and progressive implementation are important for accreditation of surgeons and teams for each specific intervention, with the ultimate aim of improving surgical safety and patient outcomes [5] and [11].

To date, three basic curricula for training and assessment of robotic surgeons have been developed and reported in the literature [3], [4], and [17]. It has been shown that they are valid, feasible, and effective in significantly improving basic robotic surgery skills. However, these curricula do not include modular training in the operating room and they have not been validated for specific procedures.

On the basis of these considerations, the ERUS board members designed and proposed a curriculum for RARP including simulation-based and modular console training with an expert mentor. The curriculum content was finalized in accordance with the expert opinion of robotic surgeons across various regions to ensure content validation [12] . The program is a step forward from existing approaches because it includes all the simulation training modalities available (virtual reality simulation, bench-top models, live animal surgery, and cadaveric procedures) combined with clinical training in the form of a mini-fellowship. Fellowships are actually considered a key component of training for complex urologic procedures such as RARP [18] .

An ideal training program should be feasible, acceptable, valid, and economically sustainable, with an effective educational impact [15] . Our results show that the EAU robotic training curriculum is feasible and acceptable, as all participants were very satisfied with the program and would highly recommend it to other colleagues. All modules of the curriculum were found to be useful, although the fellows subjectively found the virtual reality simulation training, the dry and wet laboratories, and the cadaver training particularly valuable. These data suggest that all these elements should ideally be integrated in training programs, although there are cost, ethical, and regulatory issues to take into account. The centralization of simulation training in an intensive week at a single, fully equipped training centre was well perceived and proved to be effective, as previously demonstrated in other studies [19] .

An effective simulation-based training program represents the ideal background for clinical training in the operating room. The concept of modular training proposed by Stolzenburg et al [14] for laparoscopic radical prostatectomy was adopted in the curriculum for progressive, proficiency-based training of a fellow through steps of increasing levels of difficulty in a surgical procedure. This strategy has the potential to overcome the problems of teaching complex surgical procedures, allowing safe training of surgeons with limited expertise and potentially accelerating their learning curve. The importance of proper mentoring for effective modular training has recently been highlighted [18] .

This pilot study showed that the EAU robotic training curriculum can effectively improve the basic robotic skills of participants, as demonstrated by the significant improvement in overall scores achieved by fellows at the end of the curriculum for all dVSS tasks. The first weeks of simulation training were found to be particularly effective in this respect, potentially allowing participants to optimize the results of subsequent training in the operating room. Importantly, at the end of the curriculum the majority of fellows were able to perform RARP with good or acceptable technical quality, as reflected by scores from mentors and blinded reviews of video-recorded surgeries. The two participants who were not deemed able to perform RARP safely and efficiently by the end of the training program were residents. This may indicate that the curriculum is more likely to be effective for urologists who have already completed their basic training in residency programs.

The curriculum also provided constructive feedback on the performance of fellows for individual procedural steps. Overall, the fellows were able to reach similar performance levels compared to expert surgeons for the easiest RARP steps, such as bladder detachment and endopelvic fascia incision. However, the experts achieved significantly better scores for challenging parts of the procedure, confirming the construct validity of the assessment. Fellows who did not reach sufficient scores for specific surgical steps will need further training before being deemed able to safely perform RARP independently.

Finally, the results indicate that the curriculum has a good educational impact, as well as face validity, defined as the extent to which the program is subjectively viewed as delivering the desired goal. In fact, the majority of the participants felt that the curriculum significantly improved their robotic skills and their ability to perform different RARP steps. However, further comparative studies and, ideally, randomized controlled trials will be needed to assess whether this curriculum is superior to traditional nonstructured training for RARP.

This study has some limitations. First, the number of participants was limited. Second, although the participants had limited previous robotic experience, they were not all completely novice to console surgery, so the results for the training program may be overestimated. The experience level of mentors was not factored in the analysis, but they were all high-volume robotic surgeons at teaching institutions. Third, modular training was not standardized and the console exposure of the participants was variable. Fourth, assessment of the technical skills of the fellows using GEARS and the procedure-specific scoring scale at the end of the training program was performed by their mentors. However, to standardize the assessment process and minimize bias due to nonblinded assessment, the mentors were informed about and educated in the use of the scoring systems. Fifth, the performance of fellows in RARP video clips was assessed using a new scoring tool. The contents of this scoring criterion were developed and validated on the basis of expert opinion. Sixth, a 3-mo training program may be too short for some fellows to achieve sufficient skills to adequately perform complex parts of the procedure. Finally, there was no specific training or proper pre- and post-training assessment of nontechnical skills.

This study represents the first step towards the definition of an ideal training program for RARP and of criteria for accreditation of surgeons for this procedure. Further studies need to be carried out to address the issues associated with certification and recertification using training curricula.

The concept of surgical training has been evolving in the last decade from the traditional concept of “see one, do one, teach one” towards better defined and standardized methodologies for surgical education based on the development of skill-based curricula [1], [2], [3], [4], and [5]. Furthermore, the development and diffusion of surgical robotic platforms are increasingly supporting the development, use, and validation of simulation-based training methods ranging from bench-top synthetic models, animal, and cadavers to high-fidelity virtual training platforms [6], [7], and [8]. Simulation-based training should be an essential part of surgical training programs to significantly improve the technical and nontechnical skills of trainees, shorten their learning curves for different procedures, and improve surgical safety [9] and [10].

Nevertheless, training for robotic techniques remains mainly unstructured. There has been a recent call by various training bodies for the development of well-organized educational curricula to increase preclinical exposure and of validated assessment tools that allow constructive feedback for performance improvement. These curricula, as well as proficiency-based credential processes, are important for improving patient safety and surgical outcomes in urological surgery [5] and [11].

On the basis of these considerations, the European Association of Urology (EAU) Robotic Urologic Section (ERUS) has designed and developed a structured training program and curriculum in urology that focuses on robot-assisted radical prostatectomy (RARP). The aim of the present study was to assess the feasibility, acceptability, face validity, and educational impact of this curriculum, and to assess improvements in performance and ability to perform RARP after completion of the curriculum.

3. Results

The characteristics and previous robotic experience of the participants are reported in Table 1 . Most participants had minimal or no previous experience of simulation-based training. The median times of involvement as a table assistant and a console surgeon at baseline were 9.5 mo (IQR 5.75–16 mo) and 4 mo (IQR 0–6.5 mo), respectively.

All participants completed the required e-learning module and passed the final test for assessment of theoretical knowledge. All fellows observed and assisted in the recommended number of procedures (>12 cases) during the first 3 wk of the curriculum, participated successfully in all activities during the intensive week of laboratory training, and completed the 8 wk of supervised modular training. The median number of RARPs they were involved in as console surgeons during modular training was 18 (IQR 14–36).

The overall scores obtained by participants for performance of four different dVSS tasks at baseline, during the training program (weeks 4 and 5), and at the end of the curriculum are reported in Figure 2 . For all exercises the overall score significantly increased over the training period (p < 0.001–0.005).

Fig. 2 Progressive improvement in overall scores for different tasks on the da Vinci surgical simulator before, during (weeks 4 and 5), and after completion of the curriculum. * Significant difference compared to overall score before the curriculum (p < 0.05).° Significant difference compared to overall score in week 4 (p < 0.05).

The GEARS scale was used by mentors to evaluate the final RARP performance of fellows ( Fig. 3 A). Good to excellent scores were obtained by 80–100% of trainees for their depth perception (median 5, IQR 4–5), bimanual dexterity (median 4.5, IQR 4–5), efficiency (median 4, IQR 3.75–5), force sensitivity (median 4, IQR 4–5), autonomy (median 4, IQR 3.75–5), and robotic control (median 5, IQR 3.75–5) skills. A procedure-specific scale was used to score the performance of fellows for each RARP surgical step ( Fig. 3 B).

Fig. 3 Mentor assessment of robot-assisted radical prostatectomy performance at the end of the European robot-assisted urologic training curriculum using (A) the GEARS scale and (B) a procedure-specific scale.

Eight trainees (80%) were considered by their mentors able to perform a RARP independently, safely, and efficiently on completion of the curriculum. Three (30%) were considered able to perform a complex RARP independently, safely, and effectively.

The blinded video-based assessment results for RARP steps performed by each fellow and two robotic experts are shown in Table 2 . The fellows achieved an average score that was considered safe (≥10) for all surgical steps. The highest average scores were obtained for bladder detachment and urethrovesical anastomosis. When the scores for all procedural steps were assessed, eight fellows (80%) reached an average score ≥10. The two participants who did not reach an average sufficient score were residents. The robotic experts significantly outperformed the fellows overall (mean score 13.6 vs 11) and for all RARP steps except bladder detachment and endopelvic fascia incision, confirming the construct validity of the assessment ( Fig. 4 ).

Fig. 4 Comparison of robot-assisted radical prostatectomy performance between fellows and experts using a generic dedicated scoring scale (range 4–16).

The results for quantitative surveys completed at the end of curriculum are reported in Figure 5 . All fellows gave an excellent overall evaluation of the training program and felt that the curriculum was very effective in improving their console exposure, their basic robotic skills, and their ability to perform RARP.

Fig. 5 Assessment of the educational impact, face validity, feasibility, and acceptability of the European Association of Urology Robotic Training Curriculum via quantitative surveys.

This is the first study that incorporates and validates different components of a training curriculum for robot-assisted surgery at a multi-institutional level. The study demonstrates that a 12-wk structured training program including theoretical e-learning, laboratory training, and modular training in the operating room is feasible, acceptable, and effective in improving the technical robotic skills and ability of young surgeons with limited previous robotic experience to perform the surgical steps of RARP. The study also demonstrates the face validity of this curriculum.

In the last few years there has been growing interest in the field of surgical education, especially in minimally invasive laparoscopic and robotic surgery [3], [4], [9], and [10]. However, curricula for training in robotic urologic procedures have not yet been standardized and the optimal integration of simulation-based training in surgical training programs is not clearly defined or evidence-based. The definition of curricula for each surgical procedure and their validation and progressive implementation are important for accreditation of surgeons and teams for each specific intervention, with the ultimate aim of improving surgical safety and patient outcomes [5] and [11].

To date, three basic curricula for training and assessment of robotic surgeons have been developed and reported in the literature [3], [4], and [17]. It has been shown that they are valid, feasible, and effective in significantly improving basic robotic surgery skills. However, these curricula do not include modular training in the operating room and they have not been validated for specific procedures.

On the basis of these considerations, the ERUS board members designed and proposed a curriculum for RARP including simulation-based and modular console training with an expert mentor. The curriculum content was finalized in accordance with the expert opinion of robotic surgeons across various regions to ensure content validation [12] . The program is a step forward from existing approaches because it includes all the simulation training modalities available (virtual reality simulation, bench-top models, live animal surgery, and cadaveric procedures) combined with clinical training in the form of a mini-fellowship. Fellowships are actually considered a key component of training for complex urologic procedures such as RARP [18] .

An ideal training program should be feasible, acceptable, valid, and economically sustainable, with an effective educational impact [15] . Our results show that the EAU robotic training curriculum is feasible and acceptable, as all participants were very satisfied with the program and would highly recommend it to other colleagues. All modules of the curriculum were found to be useful, although the fellows subjectively found the virtual reality simulation training, the dry and wet laboratories, and the cadaver training particularly valuable. These data suggest that all these elements should ideally be integrated in training programs, although there are cost, ethical, and regulatory issues to take into account. The centralization of simulation training in an intensive week at a single, fully equipped training centre was well perceived and proved to be effective, as previously demonstrated in other studies [19] .

An effective simulation-based training program represents the ideal background for clinical training in the operating room. The concept of modular training proposed by Stolzenburg et al [14] for laparoscopic radical prostatectomy was adopted in the curriculum for progressive, proficiency-based training of a fellow through steps of increasing levels of difficulty in a surgical procedure. This strategy has the potential to overcome the problems of teaching complex surgical procedures, allowing safe training of surgeons with limited expertise and potentially accelerating their learning curve. The importance of proper mentoring for effective modular training has recently been highlighted [18] .

This pilot study showed that the EAU robotic training curriculum can effectively improve the basic robotic skills of participants, as demonstrated by the significant improvement in overall scores achieved by fellows at the end of the curriculum for all dVSS tasks. The first weeks of simulation training were found to be particularly effective in this respect, potentially allowing participants to optimize the results of subsequent training in the operating room. Importantly, at the end of the curriculum the majority of fellows were able to perform RARP with good or acceptable technical quality, as reflected by scores from mentors and blinded reviews of video-recorded surgeries. The two participants who were not deemed able to perform RARP safely and efficiently by the end of the training program were residents. This may indicate that the curriculum is more likely to be effective for urologists who have already completed their basic training in residency programs.

The curriculum also provided constructive feedback on the performance of fellows for individual procedural steps. Overall, the fellows were able to reach similar performance levels compared to expert surgeons for the easiest RARP steps, such as bladder detachment and endopelvic fascia incision. However, the experts achieved significantly better scores for challenging parts of the procedure, confirming the construct validity of the assessment. Fellows who did not reach sufficient scores for specific surgical steps will need further training before being deemed able to safely perform RARP independently.

Finally, the results indicate that the curriculum has a good educational impact, as well as face validity, defined as the extent to which the program is subjectively viewed as delivering the desired goal. In fact, the majority of the participants felt that the curriculum significantly improved their robotic skills and their ability to perform different RARP steps. However, further comparative studies and, ideally, randomized controlled trials will be needed to assess whether this curriculum is superior to traditional nonstructured training for RARP.

This study has some limitations. First, the number of participants was limited. Second, although the participants had limited previous robotic experience, they were not all completely novice to console surgery, so the results for the training program may be overestimated. The experience level of mentors was not factored in the analysis, but they were all high-volume robotic surgeons at teaching institutions. Third, modular training was not standardized and the console exposure of the participants was variable. Fourth, assessment of the technical skills of the fellows using GEARS and the procedure-specific scoring scale at the end of the training program was performed by their mentors. However, to standardize the assessment process and minimize bias due to nonblinded assessment, the mentors were informed about and educated in the use of the scoring systems. Fifth, the performance of fellows in RARP video clips was assessed using a new scoring tool. The contents of this scoring criterion were developed and validated on the basis of expert opinion. Sixth, a 3-mo training program may be too short for some fellows to achieve sufficient skills to adequately perform complex parts of the procedure. Finally, there was no specific training or proper pre- and post-training assessment of nontechnical skills.

This study represents the first step towards the definition of an ideal training program for RARP and of criteria for accreditation of surgeons for this procedure. Further studies need to be carried out to address the issues associated with certification and recertification using training curricula.

The concept of surgical training has been evolving in the last decade from the traditional concept of “see one, do one, teach one” towards better defined and standardized methodologies for surgical education based on the development of skill-based curricula [1], [2], [3], [4], and [5]. Furthermore, the development and diffusion of surgical robotic platforms are increasingly supporting the development, use, and validation of simulation-based training methods ranging from bench-top synthetic models, animal, and cadavers to high-fidelity virtual training platforms [6], [7], and [8]. Simulation-based training should be an essential part of surgical training programs to significantly improve the technical and nontechnical skills of trainees, shorten their learning curves for different procedures, and improve surgical safety [9] and [10].

Nevertheless, training for robotic techniques remains mainly unstructured. There has been a recent call by various training bodies for the development of well-organized educational curricula to increase preclinical exposure and of validated assessment tools that allow constructive feedback for performance improvement. These curricula, as well as proficiency-based credential processes, are important for improving patient safety and surgical outcomes in urological surgery [5] and [11].

On the basis of these considerations, the European Association of Urology (EAU) Robotic Urologic Section (ERUS) has designed and developed a structured training program and curriculum in urology that focuses on robot-assisted radical prostatectomy (RARP). The aim of the present study was to assess the feasibility, acceptability, face validity, and educational impact of this curriculum, and to assess improvements in performance and ability to perform RARP after completion of the curriculum.

3. Results

The characteristics and previous robotic experience of the participants are reported in Table 1 . Most participants had minimal or no previous experience of simulation-based training. The median times of involvement as a table assistant and a console surgeon at baseline were 9.5 mo (IQR 5.75–16 mo) and 4 mo (IQR 0–6.5 mo), respectively.

All participants completed the required e-learning module and passed the final test for assessment of theoretical knowledge. All fellows observed and assisted in the recommended number of procedures (>12 cases) during the first 3 wk of the curriculum, participated successfully in all activities during the intensive week of laboratory training, and completed the 8 wk of supervised modular training. The median number of RARPs they were involved in as console surgeons during modular training was 18 (IQR 14–36).

The overall scores obtained by participants for performance of four different dVSS tasks at baseline, during the training program (weeks 4 and 5), and at the end of the curriculum are reported in Figure 2 . For all exercises the overall score significantly increased over the training period (p < 0.001–0.005).

Fig. 2 Progressive improvement in overall scores for different tasks on the da Vinci surgical simulator before, during (weeks 4 and 5), and after completion of the curriculum. * Significant difference compared to overall score before the curriculum (p < 0.05).° Significant difference compared to overall score in week 4 (p < 0.05).

The GEARS scale was used by mentors to evaluate the final RARP performance of fellows ( Fig. 3 A). Good to excellent scores were obtained by 80–100% of trainees for their depth perception (median 5, IQR 4–5), bimanual dexterity (median 4.5, IQR 4–5), efficiency (median 4, IQR 3.75–5), force sensitivity (median 4, IQR 4–5), autonomy (median 4, IQR 3.75–5), and robotic control (median 5, IQR 3.75–5) skills. A procedure-specific scale was used to score the performance of fellows for each RARP surgical step ( Fig. 3 B).

Fig. 3 Mentor assessment of robot-assisted radical prostatectomy performance at the end of the European robot-assisted urologic training curriculum using (A) the GEARS scale and (B) a procedure-specific scale.

Eight trainees (80%) were considered by their mentors able to perform a RARP independently, safely, and efficiently on completion of the curriculum. Three (30%) were considered able to perform a complex RARP independently, safely, and effectively.

The blinded video-based assessment results for RARP steps performed by each fellow and two robotic experts are shown in Table 2 . The fellows achieved an average score that was considered safe (≥10) for all surgical steps. The highest average scores were obtained for bladder detachment and urethrovesical anastomosis. When the scores for all procedural steps were assessed, eight fellows (80%) reached an average score ≥10. The two participants who did not reach an average sufficient score were residents. The robotic experts significantly outperformed the fellows overall (mean score 13.6 vs 11) and for all RARP steps except bladder detachment and endopelvic fascia incision, confirming the construct validity of the assessment ( Fig. 4 ).

Fig. 4 Comparison of robot-assisted radical prostatectomy performance between fellows and experts using a generic dedicated scoring scale (range 4–16).

The results for quantitative surveys completed at the end of curriculum are reported in Figure 5 . All fellows gave an excellent overall evaluation of the training program and felt that the curriculum was very effective in improving their console exposure, their basic robotic skills, and their ability to perform RARP.

Fig. 5 Assessment of the educational impact, face validity, feasibility, and acceptability of the European Association of Urology Robotic Training Curriculum via quantitative surveys.

This is the first study that incorporates and validates different components of a training curriculum for robot-assisted surgery at a multi-institutional level. The study demonstrates that a 12-wk structured training program including theoretical e-learning, laboratory training, and modular training in the operating room is feasible, acceptable, and effective in improving the technical robotic skills and ability of young surgeons with limited previous robotic experience to perform the surgical steps of RARP. The study also demonstrates the face validity of this curriculum.

In the last few years there has been growing interest in the field of surgical education, especially in minimally invasive laparoscopic and robotic surgery [3], [4], [9], and [10]. However, curricula for training in robotic urologic procedures have not yet been standardized and the optimal integration of simulation-based training in surgical training programs is not clearly defined or evidence-based. The definition of curricula for each surgical procedure and their validation and progressive implementation are important for accreditation of surgeons and teams for each specific intervention, with the ultimate aim of improving surgical safety and patient outcomes [5] and [11].

To date, three basic curricula for training and assessment of robotic surgeons have been developed and reported in the literature [3], [4], and [17]. It has been shown that they are valid, feasible, and effective in significantly improving basic robotic surgery skills. However, these curricula do not include modular training in the operating room and they have not been validated for specific procedures.

On the basis of these considerations, the ERUS board members designed and proposed a curriculum for RARP including simulation-based and modular console training with an expert mentor. The curriculum content was finalized in accordance with the expert opinion of robotic surgeons across various regions to ensure content validation [12] . The program is a step forward from existing approaches because it includes all the simulation training modalities available (virtual reality simulation, bench-top models, live animal surgery, and cadaveric procedures) combined with clinical training in the form of a mini-fellowship. Fellowships are actually considered a key component of training for complex urologic procedures such as RARP [18] .

An ideal training program should be feasible, acceptable, valid, and economically sustainable, with an effective educational impact [15] . Our results show that the EAU robotic training curriculum is feasible and acceptable, as all participants were very satisfied with the program and would highly recommend it to other colleagues. All modules of the curriculum were found to be useful, although the fellows subjectively found the virtual reality simulation training, the dry and wet laboratories, and the cadaver training particularly valuable. These data suggest that all these elements should ideally be integrated in training programs, although there are cost, ethical, and regulatory issues to take into account. The centralization of simulation training in an intensive week at a single, fully equipped training centre was well perceived and proved to be effective, as previously demonstrated in other studies [19] .

An effective simulation-based training program represents the ideal background for clinical training in the operating room. The concept of modular training proposed by Stolzenburg et al [14] for laparoscopic radical prostatectomy was adopted in the curriculum for progressive, proficiency-based training of a fellow through steps of increasing levels of difficulty in a surgical procedure. This strategy has the potential to overcome the problems of teaching complex surgical procedures, allowing safe training of surgeons with limited expertise and potentially accelerating their learning curve. The importance of proper mentoring for effective modular training has recently been highlighted [18] .

This pilot study showed that the EAU robotic training curriculum can effectively improve the basic robotic skills of participants, as demonstrated by the significant improvement in overall scores achieved by fellows at the end of the curriculum for all dVSS tasks. The first weeks of simulation training were found to be particularly effective in this respect, potentially allowing participants to optimize the results of subsequent training in the operating room. Importantly, at the end of the curriculum the majority of fellows were able to perform RARP with good or acceptable technical quality, as reflected by scores from mentors and blinded reviews of video-recorded surgeries. The two participants who were not deemed able to perform RARP safely and efficiently by the end of the training program were residents. This may indicate that the curriculum is more likely to be effective for urologists who have already completed their basic training in residency programs.

The curriculum also provided constructive feedback on the performance of fellows for individual procedural steps. Overall, the fellows were able to reach similar performance levels compared to expert surgeons for the easiest RARP steps, such as bladder detachment and endopelvic fascia incision. However, the experts achieved significantly better scores for challenging parts of the procedure, confirming the construct validity of the assessment. Fellows who did not reach sufficient scores for specific surgical steps will need further training before being deemed able to safely perform RARP independently.

Finally, the results indicate that the curriculum has a good educational impact, as well as face validity, defined as the extent to which the program is subjectively viewed as delivering the desired goal. In fact, the majority of the participants felt that the curriculum significantly improved their robotic skills and their ability to perform different RARP steps. However, further comparative studies and, ideally, randomized controlled trials will be needed to assess whether this curriculum is superior to traditional nonstructured training for RARP.

This study has some limitations. First, the number of participants was limited. Second, although the participants had limited previous robotic experience, they were not all completely novice to console surgery, so the results for the training program may be overestimated. The experience level of mentors was not factored in the analysis, but they were all high-volume robotic surgeons at teaching institutions. Third, modular training was not standardized and the console exposure of the participants was variable. Fourth, assessment of the technical skills of the fellows using GEARS and the procedure-specific scoring scale at the end of the training program was performed by their mentors. However, to standardize the assessment process and minimize bias due to nonblinded assessment, the mentors were informed about and educated in the use of the scoring systems. Fifth, the performance of fellows in RARP video clips was assessed using a new scoring tool. The contents of this scoring criterion were developed and validated on the basis of expert opinion. Sixth, a 3-mo training program may be too short for some fellows to achieve sufficient skills to adequately perform complex parts of the procedure. Finally, there was no specific training or proper pre- and post-training assessment of nontechnical skills.

This study represents the first step towards the definition of an ideal training program for RARP and of criteria for accreditation of surgeons for this procedure. Further studies need to be carried out to address the issues associated with certification and recertification using training curricula.

The concept of surgical training has been evolving in the last decade from the traditional concept of “see one, do one, teach one” towards better defined and standardized methodologies for surgical education based on the development of skill-based curricula [1], [2], [3], [4], and [5]. Furthermore, the development and diffusion of surgical robotic platforms are increasingly supporting the development, use, and validation of simulation-based training methods ranging from bench-top synthetic models, animal, and cadavers to high-fidelity virtual training platforms [6], [7], and [8]. Simulation-based training should be an essential part of surgical training programs to significantly improve the technical and nontechnical skills of trainees, shorten their learning curves for different procedures, and improve surgical safety [9] and [10].

Nevertheless, training for robotic techniques remains mainly unstructured. There has been a recent call by various training bodies for the development of well-organized educational curricula to increase preclinical exposure and of validated assessment tools that allow constructive feedback for performance improvement. These curricula, as well as proficiency-based credential processes, are important for improving patient safety and surgical outcomes in urological surgery [5] and [11].

On the basis of these considerations, the European Association of Urology (EAU) Robotic Urologic Section (ERUS) has designed and developed a structured training program and curriculum in urology that focuses on robot-assisted radical prostatectomy (RARP). The aim of the present study was to assess the feasibility, acceptability, face validity, and educational impact of this curriculum, and to assess improvements in performance and ability to perform RARP after completion of the curriculum.

3. Results

The characteristics and previous robotic experience of the participants are reported in Table 1 . Most participants had minimal or no previous experience of simulation-based training. The median times of involvement as a table assistant and a console surgeon at baseline were 9.5 mo (IQR 5.75–16 mo) and 4 mo (IQR 0–6.5 mo), respectively.

All participants completed the required e-learning module and passed the final test for assessment of theoretical knowledge. All fellows observed and assisted in the recommended number of procedures (>12 cases) during the first 3 wk of the curriculum, participated successfully in all activities during the intensive week of laboratory training, and completed the 8 wk of supervised modular training. The median number of RARPs they were involved in as console surgeons during modular training was 18 (IQR 14–36).

The overall scores obtained by participants for performance of four different dVSS tasks at baseline, during the training program (weeks 4 and 5), and at the end of the curriculum are reported in Figure 2 . For all exercises the overall score significantly increased over the training period (p < 0.001–0.005).

Fig. 2 Progressive improvement in overall scores for different tasks on the da Vinci surgical simulator before, during (weeks 4 and 5), and after completion of the curriculum. * Significant difference compared to overall score before the curriculum (p < 0.05).° Significant difference compared to overall score in week 4 (p < 0.05).

The GEARS scale was used by mentors to evaluate the final RARP performance of fellows ( Fig. 3 A). Good to excellent scores were obtained by 80–100% of trainees for their depth perception (median 5, IQR 4–5), bimanual dexterity (median 4.5, IQR 4–5), efficiency (median 4, IQR 3.75–5), force sensitivity (median 4, IQR 4–5), autonomy (median 4, IQR 3.75–5), and robotic control (median 5, IQR 3.75–5) skills. A procedure-specific scale was used to score the performance of fellows for each RARP surgical step ( Fig. 3 B).

Fig. 3 Mentor assessment of robot-assisted radical prostatectomy performance at the end of the European robot-assisted urologic training curriculum using (A) the GEARS scale and (B) a procedure-specific scale.

Eight trainees (80%) were considered by their mentors able to perform a RARP independently, safely, and efficiently on completion of the curriculum. Three (30%) were considered able to perform a complex RARP independently, safely, and effectively.

The blinded video-based assessment results for RARP steps performed by each fellow and two robotic experts are shown in Table 2 . The fellows achieved an average score that was considered safe (≥10) for all surgical steps. The highest average scores were obtained for bladder detachment and urethrovesical anastomosis. When the scores for all procedural steps were assessed, eight fellows (80%) reached an average score ≥10. The two participants who did not reach an average sufficient score were residents. The robotic experts significantly outperformed the fellows overall (mean score 13.6 vs 11) and for all RARP steps except bladder detachment and endopelvic fascia incision, confirming the construct validity of the assessment ( Fig. 4 ).

Fig. 4 Comparison of robot-assisted radical prostatectomy performance between fellows and experts using a generic dedicated scoring scale (range 4–16).

The results for quantitative surveys completed at the end of curriculum are reported in Figure 5 . All fellows gave an excellent overall evaluation of the training program and felt that the curriculum was very effective in improving their console exposure, their basic robotic skills, and their ability to perform RARP.

Fig. 5 Assessment of the educational impact, face validity, feasibility, and acceptability of the European Association of Urology Robotic Training Curriculum via quantitative surveys.

This is the first study that incorporates and validates different components of a training curriculum for robot-assisted surgery at a multi-institutional level. The study demonstrates that a 12-wk structured training program including theoretical e-learning, laboratory training, and modular training in the operating room is feasible, acceptable, and effective in improving the technical robotic skills and ability of young surgeons with limited previous robotic experience to perform the surgical steps of RARP. The study also demonstrates the face validity of this curriculum.

In the last few years there has been growing interest in the field of surgical education, especially in minimally invasive laparoscopic and robotic surgery [3], [4], [9], and [10]. However, curricula for training in robotic urologic procedures have not yet been standardized and the optimal integration of simulation-based training in surgical training programs is not clearly defined or evidence-based. The definition of curricula for each surgical procedure and their validation and progressive implementation are important for accreditation of surgeons and teams for each specific intervention, with the ultimate aim of improving surgical safety and patient outcomes [5] and [11].

To date, three basic curricula for training and assessment of robotic surgeons have been developed and reported in the literature [3], [4], and [17]. It has been shown that they are valid, feasible, and effective in significantly improving basic robotic surgery skills. However, these curricula do not include modular training in the operating room and they have not been validated for specific procedures.

On the basis of these considerations, the ERUS board members designed and proposed a curriculum for RARP including simulation-based and modular console training with an expert mentor. The curriculum content was finalized in accordance with the expert opinion of robotic surgeons across various regions to ensure content validation [12] . The program is a step forward from existing approaches because it includes all the simulation training modalities available (virtual reality simulation, bench-top models, live animal surgery, and cadaveric procedures) combined with clinical training in the form of a mini-fellowship. Fellowships are actually considered a key component of training for complex urologic procedures such as RARP [18] .

An ideal training program should be feasible, acceptable, valid, and economically sustainable, with an effective educational impact [15] . Our results show that the EAU robotic training curriculum is feasible and acceptable, as all participants were very satisfied with the program and would highly recommend it to other colleagues. All modules of the curriculum were found to be useful, although the fellows subjectively found the virtual reality simulation training, the dry and wet laboratories, and the cadaver training particularly valuable. These data suggest that all these elements should ideally be integrated in training programs, although there are cost, ethical, and regulatory issues to take into account. The centralization of simulation training in an intensive week at a single, fully equipped training centre was well perceived and proved to be effective, as previously demonstrated in other studies [19] .

An effective simulation-based training program represents the ideal background for clinical training in the operating room. The concept of modular training proposed by Stolzenburg et al [14] for laparoscopic radical prostatectomy was adopted in the curriculum for progressive, proficiency-based training of a fellow through steps of increasing levels of difficulty in a surgical procedure. This strategy has the potential to overcome the problems of teaching complex surgical procedures, allowing safe training of surgeons with limited expertise and potentially accelerating their learning curve. The importance of proper mentoring for effective modular training has recently been highlighted [18] .

This pilot study showed that the EAU robotic training curriculum can effectively improve the basic robotic skills of participants, as demonstrated by the significant improvement in overall scores achieved by fellows at the end of the curriculum for all dVSS tasks. The first weeks of simulation training were found to be particularly effective in this respect, potentially allowing participants to optimize the results of subsequent training in the operating room. Importantly, at the end of the curriculum the majority of fellows were able to perform RARP with good or acceptable technical quality, as reflected by scores from mentors and blinded reviews of video-recorded surgeries. The two participants who were not deemed able to perform RARP safely and efficiently by the end of the training program were residents. This may indicate that the curriculum is more likely to be effective for urologists who have already completed their basic training in residency programs.

The curriculum also provided constructive feedback on the performance of fellows for individual procedural steps. Overall, the fellows were able to reach similar performance levels compared to expert surgeons for the easiest RARP steps, such as bladder detachment and endopelvic fascia incision. However, the experts achieved significantly better scores for challenging parts of the procedure, confirming the construct validity of the assessment. Fellows who did not reach sufficient scores for specific surgical steps will need further training before being deemed able to safely perform RARP independently.

Finally, the results indicate that the curriculum has a good educational impact, as well as face validity, defined as the extent to which the program is subjectively viewed as delivering the desired goal. In fact, the majority of the participants felt that the curriculum significantly improved their robotic skills and their ability to perform different RARP steps. However, further comparative studies and, ideally, randomized controlled trials will be needed to assess whether this curriculum is superior to traditional nonstructured training for RARP.

This study has some limitations. First, the number of participants was limited. Second, although the participants had limited previous robotic experience, they were not all completely novice to console surgery, so the results for the training program may be overestimated. The experience level of mentors was not factored in the analysis, but they were all high-volume robotic surgeons at teaching institutions. Third, modular training was not standardized and the console exposure of the participants was variable. Fourth, assessment of the technical skills of the fellows using GEARS and the procedure-specific scoring scale at the end of the training program was performed by their mentors. However, to standardize the assessment process and minimize bias due to nonblinded assessment, the mentors were informed about and educated in the use of the scoring systems. Fifth, the performance of fellows in RARP video clips was assessed using a new scoring tool. The contents of this scoring criterion were developed and validated on the basis of expert opinion. Sixth, a 3-mo training program may be too short for some fellows to achieve sufficient skills to adequately perform complex parts of the procedure. Finally, there was no specific training or proper pre- and post-training assessment of nontechnical skills.

This study represents the first step towards the definition of an ideal training program for RARP and of criteria for accreditation of surgeons for this procedure. Further studies need to be carried out to address the issues associated with certification and recertification using training curricula.

The concept of surgical training has been evolving in the last decade from the traditional concept of “see one, do one, teach one” towards better defined and standardized methodologies for surgical education based on the development of skill-based curricula [1], [2], [3], [4], and [5]. Furthermore, the development and diffusion of surgical robotic platforms are increasingly supporting the development, use, and validation of simulation-based training methods ranging from bench-top synthetic models, animal, and cadavers to high-fidelity virtual training platforms [6], [7], and [8]. Simulation-based training should be an essential part of surgical training programs to significantly improve the technical and nontechnical skills of trainees, shorten their learning curves for different procedures, and improve surgical safety [9] and [10].

Nevertheless, training for robotic techniques remains mainly unstructured. There has been a recent call by various training bodies for the development of well-organized educational curricula to increase preclinical exposure and of validated assessment tools that allow constructive feedback for performance improvement. These curricula, as well as proficiency-based credential processes, are important for improving patient safety and surgical outcomes in urological surgery [5] and [11].

On the basis of these considerations, the European Association of Urology (EAU) Robotic Urologic Section (ERUS) has designed and developed a structured training program and curriculum in urology that focuses on robot-assisted radical prostatectomy (RARP). The aim of the present study was to assess the feasibility, acceptability, face validity, and educational impact of this curriculum, and to assess improvements in performance and ability to perform RARP after completion of the curriculum.

3. Results

The characteristics and previous robotic experience of the participants are reported in Table 1 . Most participants had minimal or no previous experience of simulation-based training. The median times of involvement as a table assistant and a console surgeon at baseline were 9.5 mo (IQR 5.75–16 mo) and 4 mo (IQR 0–6.5 mo), respectively.

All participants completed the required e-learning module and passed the final test for assessment of theoretical knowledge. All fellows observed and assisted in the recommended number of procedures (>12 cases) during the first 3 wk of the curriculum, participated successfully in all activities during the intensive week of laboratory training, and completed the 8 wk of supervised modular training. The median number of RARPs they were involved in as console surgeons during modular training was 18 (IQR 14–36).

The overall scores obtained by participants for performance of four different dVSS tasks at baseline, during the training program (weeks 4 and 5), and at the end of the curriculum are reported in Figure 2 . For all exercises the overall score significantly increased over the training period (p < 0.001–0.005).

Fig. 2 Progressive improvement in overall scores for different tasks on the da Vinci surgical simulator before, during (weeks 4 and 5), and after completion of the curriculum. * Significant difference compared to overall score before the curriculum (p < 0.05).° Significant difference compared to overall score in week 4 (p < 0.05).

The GEARS scale was used by mentors to evaluate the final RARP performance of fellows ( Fig. 3 A). Good to excellent scores were obtained by 80–100% of trainees for their depth perception (median 5, IQR 4–5), bimanual dexterity (median 4.5, IQR 4–5), efficiency (median 4, IQR 3.75–5), force sensitivity (median 4, IQR 4–5), autonomy (median 4, IQR 3.75–5), and robotic control (median 5, IQR 3.75–5) skills. A procedure-specific scale was used to score the performance of fellows for each RARP surgical step ( Fig. 3 B).

Fig. 3 Mentor assessment of robot-assisted radical prostatectomy performance at the end of the European robot-assisted urologic training curriculum using (A) the GEARS scale and (B) a procedure-specific scale.

Eight trainees (80%) were considered by their mentors able to perform a RARP independently, safely, and efficiently on completion of the curriculum. Three (30%) were considered able to perform a complex RARP independently, safely, and effectively.

The blinded video-based assessment results for RARP steps performed by each fellow and two robotic experts are shown in Table 2 . The fellows achieved an average score that was considered safe (≥10) for all surgical steps. The highest average scores were obtained for bladder detachment and urethrovesical anastomosis. When the scores for all procedural steps were assessed, eight fellows (80%) reached an average score ≥10. The two participants who did not reach an average sufficient score were residents. The robotic experts significantly outperformed the fellows overall (mean score 13.6 vs 11) and for all RARP steps except bladder detachment and endopelvic fascia incision, confirming the construct validity of the assessment ( Fig. 4 ).

Fig. 4 Comparison of robot-assisted radical prostatectomy performance between fellows and experts using a generic dedicated scoring scale (range 4–16).

The results for quantitative surveys completed at the end of curriculum are reported in Figure 5 . All fellows gave an excellent overall evaluation of the training program and felt that the curriculum was very effective in improving their console exposure, their basic robotic skills, and their ability to perform RARP.

Fig. 5 Assessment of the educational impact, face validity, feasibility, and acceptability of the European Association of Urology Robotic Training Curriculum via quantitative surveys.

This is the first study that incorporates and validates different components of a training curriculum for robot-assisted surgery at a multi-institutional level. The study demonstrates that a 12-wk structured training program including theoretical e-learning, laboratory training, and modular training in the operating room is feasible, acceptable, and effective in improving the technical robotic skills and ability of young surgeons with limited previous robotic experience to perform the surgical steps of RARP. The study also demonstrates the face validity of this curriculum.

In the last few years there has been growing interest in the field of surgical education, especially in minimally invasive laparoscopic and robotic surgery [3], [4], [9], and [10]. However, curricula for training in robotic urologic procedures have not yet been standardized and the optimal integration of simulation-based training in surgical training programs is not clearly defined or evidence-based. The definition of curricula for each surgical procedure and their validation and progressive implementation are important for accreditation of surgeons and teams for each specific intervention, with the ultimate aim of improving surgical safety and patient outcomes [5] and [11].

To date, three basic curricula for training and assessment of robotic surgeons have been developed and reported in the literature [3], [4], and [17]. It has been shown that they are valid, feasible, and effective in significantly improving basic robotic surgery skills. However, these curricula do not include modular training in the operating room and they have not been validated for specific procedures.

On the basis of these considerations, the ERUS board members designed and proposed a curriculum for RARP including simulation-based and modular console training with an expert mentor. The curriculum content was finalized in accordance with the expert opinion of robotic surgeons across various regions to ensure content validation [12] . The program is a step forward from existing approaches because it includes all the simulation training modalities available (virtual reality simulation, bench-top models, live animal surgery, and cadaveric procedures) combined with clinical training in the form of a mini-fellowship. Fellowships are actually considered a key component of training for complex urologic procedures such as RARP [18] .

An ideal training program should be feasible, acceptable, valid, and economically sustainable, with an effective educational impact [15] . Our results show that the EAU robotic training curriculum is feasible and acceptable, as all participants were very satisfied with the program and would highly recommend it to other colleagues. All modules of the curriculum were found to be useful, although the fellows subjectively found the virtual reality simulation training, the dry and wet laboratories, and the cadaver training particularly valuable. These data suggest that all these elements should ideally be integrated in training programs, although there are cost, ethical, and regulatory issues to take into account. The centralization of simulation training in an intensive week at a single, fully equipped training centre was well perceived and proved to be effective, as previously demonstrated in other studies [19] .

An effective simulation-based training program represents the ideal background for clinical training in the operating room. The concept of modular training proposed by Stolzenburg et al [14] for laparoscopic radical prostatectomy was adopted in the curriculum for progressive, proficiency-based training of a fellow through steps of increasing levels of difficulty in a surgical procedure. This strategy has the potential to overcome the problems of teaching complex surgical procedures, allowing safe training of surgeons with limited expertise and potentially accelerating their learning curve. The importance of proper mentoring for effective modular training has recently been highlighted [18] .

This pilot study showed that the EAU robotic training curriculum can effectively improve the basic robotic skills of participants, as demonstrated by the significant improvement in overall scores achieved by fellows at the end of the curriculum for all dVSS tasks. The first weeks of simulation training were found to be particularly effective in this respect, potentially allowing participants to optimize the results of subsequent training in the operating room. Importantly, at the end of the curriculum the majority of fellows were able to perform RARP with good or acceptable technical quality, as reflected by scores from mentors and blinded reviews of video-recorded surgeries. The two participants who were not deemed able to perform RARP safely and efficiently by the end of the training program were residents. This may indicate that the curriculum is more likely to be effective for urologists who have already completed their basic training in residency programs.

The curriculum also provided constructive feedback on the performance of fellows for individual procedural steps. Overall, the fellows were able to reach similar performance levels compared to expert surgeons for the easiest RARP steps, such as bladder detachment and endopelvic fascia incision. However, the experts achieved significantly better scores for challenging parts of the procedure, confirming the construct validity of the assessment. Fellows who did not reach sufficient scores for specific surgical steps will need further training before being deemed able to safely perform RARP independently.

Finally, the results indicate that the curriculum has a good educational impact, as well as face validity, defined as the extent to which the program is subjectively viewed as delivering the desired goal. In fact, the majority of the participants felt that the curriculum significantly improved their robotic skills and their ability to perform different RARP steps. However, further comparative studies and, ideally, randomized controlled trials will be needed to assess whether this curriculum is superior to traditional nonstructured training for RARP.

This study has some limitations. First, the number of participants was limited. Second, although the participants had limited previous robotic experience, they were not all completely novice to console surgery, so the results for the training program may be overestimated. The experience level of mentors was not factored in the analysis, but they were all high-volume robotic surgeons at teaching institutions. Third, modular training was not standardized and the console exposure of the participants was variable. Fourth, assessment of the technical skills of the fellows using GEARS and the procedure-specific scoring scale at the end of the training program was performed by their mentors. However, to standardize the assessment process and minimize bias due to nonblinded assessment, the mentors were informed about and educated in the use of the scoring systems. Fifth, the performance of fellows in RARP video clips was assessed using a new scoring tool. The contents of this scoring criterion were developed and validated on the basis of expert opinion. Sixth, a 3-mo training program may be too short for some fellows to achieve sufficient skills to adequately perform complex parts of the procedure. Finally, there was no specific training or proper pre- and post-training assessment of nontechnical skills.

This study represents the first step towards the definition of an ideal training program for RARP and of criteria for accreditation of surgeons for this procedure. Further studies need to be carried out to address the issues associated with certification and recertification using training curricula.

The concept of surgical training has been evolving in the last decade from the traditional concept of “see one, do one, teach one” towards better defined and standardized methodologies for surgical education based on the development of skill-based curricula [1], [2], [3], [4], and [5]. Furthermore, the development and diffusion of surgical robotic platforms are increasingly supporting the development, use, and validation of simulation-based training methods ranging from bench-top synthetic models, animal, and cadavers to high-fidelity virtual training platforms [6], [7], and [8]. Simulation-based training should be an essential part of surgical training programs to significantly improve the technical and nontechnical skills of trainees, shorten their learning curves for different procedures, and improve surgical safety [9] and [10].

Nevertheless, training for robotic techniques remains mainly unstructured. There has been a recent call by various training bodies for the development of well-organized educational curricula to increase preclinical exposure and of validated assessment tools that allow constructive feedback for performance improvement. These curricula, as well as proficiency-based credential processes, are important for improving patient safety and surgical outcomes in urological surgery [5] and [11].

On the basis of these considerations, the European Association of Urology (EAU) Robotic Urologic Section (ERUS) has designed and developed a structured training program and curriculum in urology that focuses on robot-assisted radical prostatectomy (RARP). The aim of the present study was to assess the feasibility, acceptability, face validity, and educational impact of this curriculum, and to assess improvements in performance and ability to perform RARP after completion of the curriculum.

3. Results

The characteristics and previous robotic experience of the participants are reported in Table 1 . Most participants had minimal or no previous experience of simulation-based training. The median times of involvement as a table assistant and a console surgeon at baseline were 9.5 mo (IQR 5.75–16 mo) and 4 mo (IQR 0–6.5 mo), respectively.

All participants completed the required e-learning module and passed the final test for assessment of theoretical knowledge. All fellows observed and assisted in the recommended number of procedures (>12 cases) during the first 3 wk of the curriculum, participated successfully in all activities during the intensive week of laboratory training, and completed the 8 wk of supervised modular training. The median number of RARPs they were involved in as console surgeons during modular training was 18 (IQR 14–36).

The overall scores obtained by participants for performance of four different dVSS tasks at baseline, during the training program (weeks 4 and 5), and at the end of the curriculum are reported in Figure 2 . For all exercises the overall score significantly increased over the training period (p < 0.001–0.005).

Fig. 2 Progressive improvement in overall scores for different tasks on the da Vinci surgical simulator before, during (weeks 4 and 5), and after completion of the curriculum. * Significant difference compared to overall score before the curriculum (p < 0.05).° Significant difference compared to overall score in week 4 (p < 0.05).

The GEARS scale was used by mentors to evaluate the final RARP performance of fellows ( Fig. 3 A). Good to excellent scores were obtained by 80–100% of trainees for their depth perception (median 5, IQR 4–5), bimanual dexterity (median 4.5, IQR 4–5), efficiency (median 4, IQR 3.75–5), force sensitivity (median 4, IQR 4–5), autonomy (median 4, IQR 3.75–5), and robotic control (median 5, IQR 3.75–5) skills. A procedure-specific scale was used to score the performance of fellows for each RARP surgical step ( Fig. 3 B).

Fig. 3 Mentor assessment of robot-assisted radical prostatectomy performance at the end of the European robot-assisted urologic training curriculum using (A) the GEARS scale and (B) a procedure-specific scale.

Eight trainees (80%) were considered by their mentors able to perform a RARP independently, safely, and efficiently on completion of the curriculum. Three (30%) were considered able to perform a complex RARP independently, safely, and effectively.

The blinded video-based assessment results for RARP steps performed by each fellow and two robotic experts are shown in Table 2 . The fellows achieved an average score that was considered safe (≥10) for all surgical steps. The highest average scores were obtained for bladder detachment and urethrovesical anastomosis. When the scores for all procedural steps were assessed, eight fellows (80%) reached an average score ≥10. The two participants who did not reach an average sufficient score were residents. The robotic experts significantly outperformed the fellows overall (mean score 13.6 vs 11) and for all RARP steps except bladder detachment and endopelvic fascia incision, confirming the construct validity of the assessment ( Fig. 4 ).

Fig. 4 Comparison of robot-assisted radical prostatectomy performance between fellows and experts using a generic dedicated scoring scale (range 4–16).

The results for quantitative surveys completed at the end of curriculum are reported in Figure 5 . All fellows gave an excellent overall evaluation of the training program and felt that the curriculum was very effective in improving their console exposure, their basic robotic skills, and their ability to perform RARP.

Fig. 5 Assessment of the educational impact, face validity, feasibility, and acceptability of the European Association of Urology Robotic Training Curriculum via quantitative surveys.

This is the first study that incorporates and validates different components of a training curriculum for robot-assisted surgery at a multi-institutional level. The study demonstrates that a 12-wk structured training program including theoretical e-learning, laboratory training, and modular training in the operating room is feasible, acceptable, and effective in improving the technical robotic skills and ability of young surgeons with limited previous robotic experience to perform the surgical steps of RARP. The study also demonstrates the face validity of this curriculum.

In the last few years there has been growing interest in the field of surgical education, especially in minimally invasive laparoscopic and robotic surgery [3], [4], [9], and [10]. However, curricula for training in robotic urologic procedures have not yet been standardized and the optimal integration of simulation-based training in surgical training programs is not clearly defined or evidence-based. The definition of curricula for each surgical procedure and their validation and progressive implementation are important for accreditation of surgeons and teams for each specific intervention, with the ultimate aim of improving surgical safety and patient outcomes [5] and [11].

To date, three basic curricula for training and assessment of robotic surgeons have been developed and reported in the literature [3], [4], and [17]. It has been shown that they are valid, feasible, and effective in significantly improving basic robotic surgery skills. However, these curricula do not include modular training in the operating room and they have not been validated for specific procedures.

On the basis of these considerations, the ERUS board members designed and proposed a curriculum for RARP including simulation-based and modular console training with an expert mentor. The curriculum content was finalized in accordance with the expert opinion of robotic surgeons across various regions to ensure content validation [12] . The program is a step forward from existing approaches because it includes all the simulation training modalities available (virtual reality simulation, bench-top models, live animal surgery, and cadaveric procedures) combined with clinical training in the form of a mini-fellowship. Fellowships are actually considered a key component of training for complex urologic procedures such as RARP [18] .

An ideal training program should be feasible, acceptable, valid, and economically sustainable, with an effective educational impact [15] . Our results show that the EAU robotic training curriculum is feasible and acceptable, as all participants were very satisfied with the program and would highly recommend it to other colleagues. All modules of the curriculum were found to be useful, although the fellows subjectively found the virtual reality simulation training, the dry and wet laboratories, and the cadaver training particularly valuable. These data suggest that all these elements should ideally be integrated in training programs, although there are cost, ethical, and regulatory issues to take into account. The centralization of simulation training in an intensive week at a single, fully equipped training centre was well perceived and proved to be effective, as previously demonstrated in other studies [19] .

An effective simulation-based training program represents the ideal background for clinical training in the operating room. The concept of modular training proposed by Stolzenburg et al [14] for laparoscopic radical prostatectomy was adopted in the curriculum for progressive, proficiency-based training of a fellow through steps of increasing levels of difficulty in a surgical procedure. This strategy has the potential to overcome the problems of teaching complex surgical procedures, allowing safe training of surgeons with limited expertise and potentially accelerating their learning curve. The importance of proper mentoring for effective modular training has recently been highlighted [18] .

This pilot study showed that the EAU robotic training curriculum can effectively improve the basic robotic skills of participants, as demonstrated by the significant improvement in overall scores achieved by fellows at the end of the curriculum for all dVSS tasks. The first weeks of simulation training were found to be particularly effective in this respect, potentially allowing participants to optimize the results of subsequent training in the operating room. Importantly, at the end of the curriculum the majority of fellows were able to perform RARP with good or acceptable technical quality, as reflected by scores from mentors and blinded reviews of video-recorded surgeries. The two participants who were not deemed able to perform RARP safely and efficiently by the end of the training program were residents. This may indicate that the curriculum is more likely to be effective for urologists who have already completed their basic training in residency programs.

The curriculum also provided constructive feedback on the performance of fellows for individual procedural steps. Overall, the fellows were able to reach similar performance levels compared to expert surgeons for the easiest RARP steps, such as bladder detachment and endopelvic fascia incision. However, the experts achieved significantly better scores for challenging parts of the procedure, confirming the construct validity of the assessment. Fellows who did not reach sufficient scores for specific surgical steps will need further training before being deemed able to safely perform RARP independently.

Finally, the results indicate that the curriculum has a good educational impact, as well as face validity, defined as the extent to which the program is subjectively viewed as delivering the desired goal. In fact, the majority of the participants felt that the curriculum significantly improved their robotic skills and their ability to perform different RARP steps. However, further comparative studies and, ideally, randomized controlled trials will be needed to assess whether this curriculum is superior to traditional nonstructured training for RARP.

This study has some limitations. First, the number of participants was limited. Second, although the participants had limited previous robotic experience, they were not all completely novice to console surgery, so the results for the training program may be overestimated. The experience level of mentors was not factored in the analysis, but they were all high-volume robotic surgeons at teaching institutions. Third, modular training was not standardized and the console exposure of the participants was variable. Fourth, assessment of the technical skills of the fellows using GEARS and the procedure-specific scoring scale at the end of the training program was performed by their mentors. However, to standardize the assessment process and minimize bias due to nonblinded assessment, the mentors were informed about and educated in the use of the scoring systems. Fifth, the performance of fellows in RARP video clips was assessed using a new scoring tool. The contents of this scoring criterion were developed and validated on the basis of expert opinion. Sixth, a 3-mo training program may be too short for some fellows to achieve sufficient skills to adequately perform complex parts of the procedure. Finally, there was no specific training or proper pre- and post-training assessment of nontechnical skills.

This study represents the first step towards the definition of an ideal training program for RARP and of criteria for accreditation of surgeons for this procedure. Further studies need to be carried out to address the issues associated with certification and recertification using training curricula.

The concept of surgical training has been evolving in the last decade from the traditional concept of “see one, do one, teach one” towards better defined and standardized methodologies for surgical education based on the development of skill-based curricula [1], [2], [3], [4], and [5]. Furthermore, the development and diffusion of surgical robotic platforms are increasingly supporting the development, use, and validation of simulation-based training methods ranging from bench-top synthetic models, animal, and cadavers to high-fidelity virtual training platforms [6], [7], and [8]. Simulation-based training should be an essential part of surgical training programs to significantly improve the technical and nontechnical skills of trainees, shorten their learning curves for different procedures, and improve surgical safety [9] and [10].

Nevertheless, training for robotic techniques remains mainly unstructured. There has been a recent call by various training bodies for the development of well-organized educational curricula to increase preclinical exposure and of validated assessment tools that allow constructive feedback for performance improvement. These curricula, as well as proficiency-based credential processes, are important for improving patient safety and surgical outcomes in urological surgery [5] and [11].

On the basis of these considerations, the European Association of Urology (EAU) Robotic Urologic Section (ERUS) has designed and developed a structured training program and curriculum in urology that focuses on robot-assisted radical prostatectomy (RARP). The aim of the present study was to assess the feasibility, acceptability, face validity, and educational impact of this curriculum, and to assess improvements in performance and ability to perform RARP after completion of the curriculum.