Beyond the console: a narrative review of robotic surgical education for urologic trainees

Introduction

Since the approval of the da Vinci system for laparoscopic surgery in 1998 (1), the scope of robotic applications has witnessed rapid expansion in all surgical specialties, particularly within urology. Procedures such as robotic prostatectomy and partial nephrectomy, introduced in the early-mid 2000s (2,3), have achieved widespread adoption, with an estimated 85–90% of radical prostatectomies now performed using robotic techniques (4). Other complex urological procedures such as ureteral reconstructions (5), radical cystectomies (6), fistula repairs (7), and lymph node dissections (8) are increasingly adopting robotic assistance to take advantage of enhanced surgical precision and control, along with its minimally invasive approach. As the utilization of robotic platforms continues to grow (4), it becomes increasingly imperative to train the next generation of urologists in the safe and competent execution of robotic-assisted surgery.

Traditionally, surgical training adhered to the Halstedian model where residents learned through supervised repetition in the operating room in a master-apprentice style system (9,10). Given the substantial learning curve for robotic surgery (2), this gradual trajectory is not sufficient for the attainment of proficiencies needed for independent practice within the finite duration of residency programs. A 2019 survey of program directors and chief residents in American urology residencies revealed major gaps in robotic surgical training. Surprisingly, 79–88% of graduating chief residents described a lack of readiness for independent practice across multiple common robotic procedures like prostatectomy, pyeloplasty, and nephrectomy, which correlated with insufficient exposure and access (11). To bridge this gap, it’s imperative to integrate more comprehensive simulation and structured robotic curricula, aligning with the plans of numerous program directors to enrich training experiences (11). This shift is vital for equipping future urologists with the necessary skills for robotic surgery.

In this narrative review, we synthesize primary literature surrounding the implementation of robotic surgical education for urology trainees. We aim to review effective educational methods, simulations, and curricular designs developed to enhance robotic proficiency. Our secondary objective is to assess the transferability of skills from training modalities to real surgical practice. Our findings will inform the design of robotic surgical education programs to equip the next generation of urologists with this essential skill set. We present this article in accordance with the Narrative Review reporting checklist (available at https://amj.amegroups.com/article/view/10.21037/amj-24-2/rc).

Methods

We performed a broad literature search on PubMed to identify original research studies published between 2013–2023 (Tables 1,2). Using predefined criteria, two reviewers independently carried out the literature screening, selection, and review. Consensus was reached on final article inclusion and exclusion using the Rayyan platform. The specific search terms utilized are included in Table 2. Inclusion criteria comprised primary research studies published in English that described and evaluated various aspects of robotic surgical education for urologic trainees. Exclusion criteria included reviews, non-urologic/non-trainee subjects, purely assessment tools, unavailable full texts, new model development, and animal research.

In total, 681 relevant papers were identified and extracted. Upon review of the abstracts and full texts in conjunction with the inclusion and exclusion criteria, 42 papers were included in the review. The papers were then grouped by whether they addressed components of structural design or the outcomes/impact of various training modalities (Figure 1).

Figure 1 Flowchart of study identification, screening, and inclusion.

Summary of findings

Structural design

Twenty-five studies were identified concerning the design of robotic surgical programs and were included in the review. The majority of the studies addressed components of curriculum design, followed by feedback and coaching, video review, and the gamification of robotic curriculum.

Curriculum design

Basic robotic skills acquisition

Four studies evaluated the validity of curricula designed to teach trainees fundamental robotic skills (12-15), including the Fundamental Skills of Robotic Surgery (FSRS) (12), Fundamentals of Robotic Surgery (FRS) (13), Fundamental Inanimate Robotic Skills Tasks (FIRST) (14), and the Basic Skills Training Curriculum (BSTC) (15). The FSRS curriculum contains 4 modules targeting basic console orientation, psychomotor skills training, basic surgical skills, and intermediate surgical skills to allow the novice surgeon to master the use of the surgical console and its associated psychomotor skills using the Robotic Surgical Simulator (RoSS) (12). The FRS curriculum is a proficiency-based curriculum with a combination of didactic modules and a simulation-based curriculum geared towards camera, arm, and instrument handling exercises for the acquisition of basic robotic surgical skills using the RobotiX Mentor platform (13). The FIRST curriculum focuses simulations on suturing, cutting, peg transfer, and needle targeting skills, all of which are key steps of the robotic prostatectomy (14). The BSTC is a four-week curriculum that consists of didactics, self-directed online modules, hands-on training with the da Vinci robot, and simulation-based training on the da Vinci Surgical Simulator (dVSS) (15).

The FSRS and FIRST curricula demonstrated the ability to discern differences in experience levels across simulated tasks (P<0.05) and differences in time to completion for experts (P<0.001) (12,14). The FRS curriculum showed pre- to post-training improvements for novices in overall Global Evaluative Assessment of Robotic Skills (GEARS) scores (P<0.001) and in all domains (depth perception, dexterity, etc.; P=0.01–0.001), as well as time (P<0.001) and errors (P=0.003) on a suturing task (13). However, the study had a high attrition rate, presumably due to resident prioritization of clinical obligations over robotic skills practice, further depicting the lack of dedicated and protected training time for surgical residents. Foell’s BSTC curriculum yielded durable gains in task time (P<0.05) but not errors at five months for all trainees. It also depicted better skill acquisition in the competency-based training group as compared to their traditional, time-based training group (15).

In summary, all curricula improved technical skills in simulation, but proficiency-based training promoted superior skill gains compared to time-based approaches. However, given the considerable heterogeneity amongst curricular elements and the lack of control groups, it remains difficult to attribute measured outcomes solely to curriculum specifics versus simply implementing a structured framework itself, as any gains could stem from the implementation of procedural sequencing, benchmarking, and skills reinforcement rather than the specific curricular design. Nevertheless, these initial findings reveal promise for standardized training in elevating competencies. Further research through larger, multi-institutional efforts is imperative to elucidate an ideal curricular design for efficiently maximizing robotic surgical proficiency.

Procedure-specific curriculum

Three studies evaluated the validity of procedure-specific curricula designed to train novices to obtain the complex skills required for a robot-assisted radical prostatectomy (RARP) (16-19). Song & Ko devised a targeted curriculum focused on urethrovesical anastomosis, incorporating nine EndoWrist manipulation exercises and advanced needle-driving tasks using the dVSS (16). Similarly, Harrison et al. introduced an original virtual training module for RARP, encompassing three critical surgical stages: bladder neck dissection, neurovascular bundle dissection, and urethrovesical anastomosis (17). Papalois et al. developed a comprehensive virtual reality (VR) anatomical curriculum, which integrated didactic videos, animations, and audio commentary, specifically tailored to enhance surgical decision-making, correlating directly with the procedural steps of robotic prostatectomy as delineated by experts (18). In addition, Fujimura et al. formulated a procedure-specific training framework that segmented the surgical procedure into essential stages under the mentorship of experienced surgeons (19). Specifically, Fujimura et al. established structured technical checkpoints and time constraints within a stepwise, mentored prostatectomy curriculum (19).

In their research, Song & Ko utilized VR simulations to effectively discern surgical skill levels among trainees, demonstrating a significant correlation (P=0.01) between simulation time and actual console time during urethrovesical anastomosis training (16). Harrison et al. further validated the effectiveness of a VR-based curriculum for radical prostatectomy, showing substantial improvements in novice metrics (P<0.005) (17). Papalois et al., focusing on a mixed reality anatomical curriculum, significantly enhanced student confidence in anatomical knowledge (P<0.001) but did not explore the curriculum’s effect on technical skill development (18). Conversely, Fujimura et al.’s study was unique in demonstrating skill transfer to the operating room and noted that novice surgeons could independently perform prostatectomies after approximately 10.7 cases without impacting operative outcomes (19).

In summary, these studies collectively highlight the impact of procedure-specific curricula in enhancing the skills required for complex robotic surgeries like radical prostatectomy and cystectomy. The integration of virtual and mixed reality elements into surgical training, as demonstrated by Song & Ko and Papalois et al., not only improves technical proficiency but also boosts confidence in anatomical knowledge (16,18). The methodical approach of Harrison et al. and the structured training modules by Fujimura et al. further emphasize the importance of tailored, step-by-step learning for novice surgeons (17,19). A notable strength of these studies is the improvement in trainee confidence, which is a significant finding given the current lack of readiness and confidence that current trainees experience (11). Further, the direct correlation between structured curricula and improved performance in the operating room underscores the effectiveness of immersive, procedure-specific training in preparing novice surgeons for the intricacies of specific robot-assisted surgeries, ultimately contributing to better surgical outcomes and patient care.

Advanced procedure-specific curricula

The European Association of Urology Robotic Urology Section (ERUS) designed a four-phase curriculum for training novice surgeons in robot-assisted radical cystectomy with intracorporeal urinary diversion (iRARC) (20). This curriculum, which includes online learning, simulation, clinical instruction, and video assessment, was tested in a 21-patient trial (20). A trainee completed 80% of the procedures and successfully executed 60% of the 209 steps in the procedure, showing progressive skill development (20). Despite longer operative times for the novice compared to an expert, key surgical outcomes like blood loss and positive surgical margins were similar (20). This research validates the ERUS curriculum as a structured, proficiency-based method for safely and effectively teaching iRARC to novice surgeons. The results suggest that such structured training can mitigate the steep learning curve associated with this complex surgery, potentially enhancing patient safety and surgical outcomes. While operating times were longer for the trainee, the comparable critical surgical outcomes suggest that this additional time investment is justified for effective learning. The study emphasizes the need for structured, methodical training in complex surgical procedures, moving beyond the traditional “see one, do one, teach one” approach. However, larger studies are required to further validate these findings and to explore scalability and adaptability across different training environments and surgeon skill levels.

Fundamental skills vs. procedure-specific curricula

Raison et al. divided novices into three groups—procedural VR training on bladder neck dissection and urethrovesical anastomosis tasks, fundamentals VR training, or no training (21). They found that any VR training resulted in significantly higher GEARS scores (P=0.002) compared to no training, but procedural trainees achieved significantly higher GEARS scores versus the fundamentals or control groups (P=0.03) (21). This finding may indicate that a more focused approach shows greater promise for improving trainee skills than curricula focused on fundamental robotic skills. Raison et al.’s study, while demonstrating the superiority of procedural VR training, must be viewed through the lens of its limited sample size of just twenty-six novice participants (21). This small cohort size raises questions about the robustness and generalizability of the findings, suggesting that larger-scale studies are necessary to firmly establish the efficacy and scope of procedural VR training in surgical education.

Optimal training time

Studies implementing structured robotic surgery curricula for both basic and complex VR simulator tasks found time to achieve expert proficiency benchmark levels ranged substantially from 5 hours to over 40 hours depending on complexity. Wiener et al.’s retrospective review determined approximately 10 hours of total training time, split evenly across five sequential 2-hour simulator sessions, enabled urologic trainees to reach proficiency across all fundamental robotic skill sets (22). In contrast, Harrison et al.’s prospective trial analyzing a procedural curriculum for radical prostatectomy modules found an estimated minimum of 40 hours were required to attain expert performance benchmarks in more complex, multi-step skills like VUA and BND (17). Further, Beulens et al. determined through a 1-day condensed training program that the majority of robotic novices were unable to reach proficiency on basic skill simulations (23). The ideal training time closely relates to task complexity, with basic components requiring less intensive time investment than full procedures. Unfortunately, long-term skill retention following structured curriculum completion was not fully addressed by any of the studies and research has shown decay without reinforcement, so ongoing practice is likely necessary (24).

Cognitive training

Raison et al.’s robotic surgery training curriculum uniquely integrated dedicated modules for mental preparation and rehearsal of both technical and non-technical operative skills (25). The latter included decision-making, communication, and coping under distractions and stressors that occur in live cases (25). Their cognitive training group demonstrated superior trainee performance for urethrovesical anastomosis, including fewer technical errors and faster times despite controlled stressor introduction compared to standard video training alone (25). No other studies included in this review evaluated the incorporation of cognitive elements for managing psychological and environmental factors that influence surgical performance. This represents an area requiring further investigation within structured training curricula as non-technical expertise remains critical for patient safety and care quality (26).

Feedback and coaching

Another aspect of curriculum design that was assessed was the effect of providing feedback and expert coaching to enhance robotic surgical skill development amongst urology trainees and faculty (27-33). Approaches included personalized proctor guidance, simulator-generated feedback, structured debrief discussions, telementoring programs, and dedicated coaching sessions.

Some studies found that personalized, expert guidance during VR simulator training led to greater improvements in robotic surgery performance metrics compared to simulator feedback alone or with no guidance (27,28). In contrast, one study showed no significant difference between proctor and simulator guidance for basic skill acquisition (29). Additionally, another study showed telementoring programs utilizing audiovisual communication platforms were found to be comparable to in-person mentoring for developing robotic surgical skills (30). Moreover, both trainees and mentors provided positive evaluations of the telementoring interface. Dedicated, structured coaching sessions between expert and novice surgeons significantly improved robotic surgery outcomes, efficiency, and learning curves, especially for more complex procedures like robotic prostatectomy (31). The incorporation of specific, goal-oriented discussions focused on surgical techniques, principles, and metrics was found to be beneficial (32). Overall, structured pre- and post-case discussions enhanced the educational experience (10) and the trainees preferred verbal feedback paired with visual demonstrations or diagrams (33).

Post-simulation video review

Studies found that allowing trainees to review videos of their own robotic surgery simulator performance improved the quality of robotic skills (34-36) and, with the addition of expert demonstrations, improved subsequent attempts and avoided recurring errors (35). Integrated video review systems increased retention and prevented skill decay compared to no video review (36). One study evaluated the transferability of skills developed with video-review augmented simulator training to performances on a physical da Vinci robot (34). While video review improved quality metrics in the simulator (fewer urethral injuries and ideal suture depth), it also led to longer time and more camera movement (34). Ultimately, when tested on an actual da Vinci system, both the video review and control groups demonstrated enhanced efficiency after their VR training (34). This suggests overall transferability of skills but may not be as a result of specifically the video review.

Supplemented video recording and video review of simulated robotic surgery exercises improved novice trainees’ performance, skill retention, and error avoidance compared to practice alone. Skills developed with video-integrated simulator training appear to positively translate to physical robotic systems. Although, potential trade-offs may exist between efficiency and quality metrics.

Trainee participation and gamification

Another method of robotic surgical training is the use of gamification, which in robotic surgery training involves the use of competitive elements like leaderboards and rewards within simulations to enhance learner engagement and skill acquisition in a dynamic, interactive environment. One study implemented a robotic surgery simulation league amongst residents, dividing participants into competitive teams with faculty coaches (37). Engagement with the dVSS increased significantly over the league’s duration, with median monthly practice time increasing from 0 to 94 minutes (37). Furthermore, the majority of residents reported gains in robotic surgery confidence, anticipated future simulator use, and operating room autonomy. In summary, exploiting gamification elements substantially increased trainee engagement with robotic surgery simulation (37).

Outcome studies

Twenty-two studies were identified concerning the impact of various robotic surgery curriculum and their ability to improve robotic ability and discriminate between novice and expert surgeons. The majority of the studies measured the translation of skills from simulations and training modalities to real operative performance, followed by studies evaluating the efficacy of different simulation modalities.

Simulation efficacy

VR simulators, like the dVSS and Mimic dV-Trainer, have demonstrated improved performance scores (38,39), efficiency (40), economy of motion (39), and error reduction (40) from baseline across a variety of tasks along with excellent face, content, and construct validity (39). Completing VR curricula enhanced skill sets that translated to subsequent efficiency and quality improvements on physical da Vinci surgical system tasks (40,41). However, studies comparing different VR simulators failed to find differences in robotic performance (42,43). Additional studies found inferior retention of proper posture, ergonomic technique, workload management, and wider operating skills after VR training alone (38,40). This suggests that simulators must place greater emphasis on reinforcing appropriate ergonomic behaviors and managing cognitive burdens through repetitive practice, detailed visual guidance, and performance feedback in these areas during the virtual training itself to drive improved retention.

Integrating VR and dry lab techniques, including animal and cadaver models, provides a comprehensive education. VR simulations can complement traditional hands-on (dry lab) training techniques as shown in a study that demonstrated equivalence in basic skill development between the two approaches (43). VR provides sophisticated metrics that adeptly distinguish between varying levels of surgical expertise (44), however dry lab training provides practical value in translating skills to live surgery (45)—a step that remains critical for comprehensive surgical preparedness. Studies indicate a more inconsistent skill transference from VR to live surgery across specific tasks (46). Overall, the research advocates for a balanced surgical training curriculum that strategically employs both VR and dry lab methods, ensuring that surgeons are equipped with the necessary skills for the dynamic environment of robotic surgery. Standardizing assessment metrics and specific simulation tasks can help demonstrate stronger evidence towards implementing effective robotic surgery simulations in urologic residency training.

Skill translation

A total of fourteen studies (10,13,21,30,34,41,44-53) analyzed the translation of robotic surgical skills from simulation modalities like the dVSS, Mimic dV-Trainer, da Vinci Surgical Skills Simulator (dVSSS), and physical dry lab models to performances on the da Vinci Si and Xi systems. The majority of studies demonstrated a positive skill translation from simulation to intraoperative performance, with greater efficiency, fewer errors, and superior technical ratings compared to basic or no training (10,13,41,44,46-51). The strength of evidence varied greatly depending on study elements like the simulation platform utilized, tasks practiced, experience level of trainees, and how clinical performance was measured.

Most of the positive skill translation was shown in early trainees without previous robotic experience (10,21,48,49,51), with all showing faster completion times, fewer errors, and superior global rating scores after structured simulation programs. On the other hand, Mills et al. found poor correlations between simulation metrics and expert video ratings of live performance in attending surgeons (53), which suggests that potential improvement from additional simulation practice may be limited in those with expert skills. Alternately, current simulators may not replicate the complex scenarios and decision-making required of experts to distinguish performance.

There was mixed evidence on the interaction of trainee experience and simulation efficacy. Volpe et al. delivered a structured twelve-week curriculum for the RARP procedure that involved e-learning, a one-week structured simulation-based learning, and supervised modular training to eight fellows and two residents (52). As a result of their structured curriculum, each fellow was deemed competent to perform a RARP independently, while the residents were not deemed competent (52), suggesting potential barriers for early trainees. A more junior level may not be a barrier to structured curricula, but a component of how simulation integrates with existing expertise on a learning curve.

The simulation modality also impacted translation success. Multimodal curricula exhibited strong positive correlations with intraoperative performance ratings (51), supporting the combined value of VR, inanimate training, and augmented procedural rehearsal. Direct comparisons found dry lab models better-prepared novices for tissue handling tasks than VR simulation alone (41). Augmented procedural training on VR simulators still led to superior cadaveric performance compared to basic skill drills or no training (21). This highlights the unique assets of both simulation approaches.

While multiple studies relied on technical skill ratings, four studies directly linked simulation and training modalities to patient outcomes. Sanford et al. established a direct link between simulation-based suturing technical skills and improved patient outcomes such as continence recovery post-robotic-assisted laparoscopic prostatectomy (RALP), emphasizing the critical role of simulation training in urology residencies (46). Similarly, Shin et al. demonstrated the safety and effectiveness of a novel telementoring interface, which may contribute to minimizing intraoperative complications by providing remote, real-time guidance during robotic procedures (30). Additionally, Wang et al. reported a notable decrease in anastomosis times during RARP following VR training, suggesting a direct benefit of simulation training on operative efficiency (49). Lastly, van der Leun et al. found that video review adjunct to VR simulation not only improved the quality of robotic skills in novice surgeons but also evidenced the transferability of those skills to the real robotic system, potentially reducing the likelihood of intraoperative errors and improving surgical precision (34). In summary, the evidence robustly indicates that simulation training, supplemented by innovative approaches like telementoring and video review, not only enhances technical proficiency but also has a demonstrable and positive impact on patient outcomes, particularly benefiting early trainees and those engaged in multi-modal curricula.

Our findings have several implications for residency program directors and urologists in training. Firstly, self-guided robotic skill attainment may be inefficient, warranting deliberate, milestone-driven training in the form of a structured curriculum. Additionally, metrics-based individualized feedback mechanisms should complement structured curricula for highlighting progress and retention deficiencies. The infrastructure for training including protected simulation time, ease of simulation access, multidisciplinary faculty support, and tele-mentoring continuity must expand to meet our new reality of predominantly robotic urologic practice. The curricular structure should also align with individual learning curves, blending various modalities like simulations, dry labs, and graduated autonomy. Initial stages of training should emphasize fundamental skills, particularly for novice surgeons, before progressing to full procedural rehearsals. As trainees gain experience, shifting focus to procedure-specific curricula may be advantageous. Moreover, implementing hybrid training models and conducting longitudinal assessments are vital to continually evaluate skill retention and identify any decline in abilities over time. Just as our patient care models have rapidly evolved, so too must clinical education to deliver comprehensive, sustainable surgeon development programs benefitting individuals at all stages while ultimately elevating care quality and safety.

Quality of research and future investigation

This review possesses considerable strengths, including the comprehensive inclusion of primary research on robotic training approaches over the past decade, yielding a robust evidence base for qualitative synthesis. Our structured analysis process facilitated an effective comparison of modalities and curricula. We examined studies spanning fundamentals to complex procedures using various simulation platforms and live skill translation data. However, limitations existed regarding between-study heterogeneity and variability in methodology. The majority focused on simulations rather than patient outcomes, had small sample sizes, examined interventions in isolation, lacked comparison groups, and did not address long-term retention. Additionally, there was a notable absence of data within the studies regarding the cost-effectiveness of robotic surgical training modalities, making it crucial that future studies quantify the economic implications of simulation-based education. Few studies have directly compared modalities or curricula head-to-head. Thus, there remains a profound need for large multi-institutional efforts to validate standardized, milestone-driven curricula and assessments across platforms to achieve efficient competency. Additional research must shift focus toward identifying best practices for safely, sustainably transitioning novice urologists into the independent practice of proficient robotic surgery through optimized, evidence-based training redesign.

Conclusions

Robotic surgery has transformed urologic practice, requiring comprehensive reevaluation of residency education to prepare the next generation of competent robotic surgeons. This review identified significant evidence surrounding beneficial modalities for accelerating both the technical and non-technical skill development required for robotic surgery practice. Structured curricula, individualized expert guidance, video-integrated simulation, and multimodality training approaches all demonstrate viability.

Future research in robotic surgery education must prioritize filling existing gaps. Comparative studies of fundamental curricula should incorporate control groups to better understand the impact of specific curriculum elements versus structured, progression-based learning. Large-scale research comparing procedure-specific and fundamental curricula is essential to inform the development of graduated curricula as well as studies on skill retention and decay through various training modes are needed. Ultimately, understanding how training influences patient outcomes in clinical practice will be key to developing a comprehensive, evidence-based curriculum for robotic surgery education.

Acknowledgments

Authors would like to thank Imelda L. Vetter for her assistance with developing a search strategy.

Funding: None.

Footnote

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://amj.amegroups.com/article/view/10.21037/amj-24-2/rc

Peer Review File: Available at https://amj.amegroups.com/article/view/10.21037/amj-24-2/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://amj.amegroups.com/article/view/10.21037/amj-24-2/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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