title: Structured and Modular Training Pathway for Robot-assisted Radical Prostatectomy (RARP): Validation of the RARP Assessment Score and Learning Curve Assessment.
abstract: BACKGROUND
  Use of robot-assisted radical prostatectomy (RARP) for prostate cancer is increasing. Structured surgical training and objective assessment are critical for outcomes.
  
  
  OBJECTIVE
  To develop and validate a modular training and assessment pathway via Healthcare Failure Mode and Effect Analysis (HFMEA) for trainees undertaking RARP and evaluate learning curves (LCs) for procedural steps.
  
  
  METHODS
  This multi-institutional (Europe, Australia, and United States) observational prospective study used HFMEA to identify the high-risk steps of RARP. A specialist focus group enabled validation. Fifteen trainees who underwent European Association of Urology robotic surgery curriculum training performed RARP and were assessed by mentors using the tool developed. Results produced LCs for each step. A plateau above score 4 indicated competence.
  
  
  METHODS
  We used a modular training and assessment tool (RARP Assessment Score) to evaluate technical skills. LCs were constructed. Multivariable Kruskal-Wallis, Mann-Whitney U, and κ coefficient analyses were used.
  
  
  CONCLUSIONS
  Five surgeons were observed for 42 console hours to map steps of RARP. HFMEA identified 84 failure modes and 46 potential causes with a hazard score ≥8. Content validation created the RARP Assessment Score: 17 stages and 41 steps. The RARP Assessment Score was acceptable (56.67%), feasible (96.67%), and had educational impact (100%). Fifteen robotic surgery trainees were assessed for 8 mo. In 426 RARP cases (range: 4-79), all procedural steps were attempted by trainees. Trainees were assessed with the RARP Assessment Score by their expert mentors, and LCs for individual steps were plotted. LCs demonstrated plateaus for anterior bladder neck transection (16 cases), posterior bladder neck transection (18 cases), posterior dissection (9 cases), dissection of prostatic pedicle and seminal vesicles (15 cases), and anastomosis (17 cases). Other steps did not plateau during data collection.
  
  
  CONCLUSIONS
  The RARP Assessment Score based on HFMEA methodology identified critical steps for focused RARP training and assessed surgeons. LCs demonstrate the experience necessary to reach a level of competence in technical skills to protect patients.
  
  
  RESULTS
  We developed a safety and assessment tool to gauge the technical skills of surgeons performing robot-assisted radical prostatectomy. Improvement was monitored, and measures of progress can be used in future to guide mentors when training surgeons to operate safely.
authors.affiliation: King's College London, Guy's Hospital, London, UK.
authors.forename: Catherine
authors.initials: C
authors.lastname: Lovegrove
authors.affiliation: University of Padua, Padua, Italy.
authors.forename: Giacomo
authors.initials: G
authors.lastname: Novara
authors.affiliation: OLV Clinic, Aalst, Belgium.
authors.forename: Alex
authors.initials: A
authors.lastname: Mottrie
authors.affiliation: Roswell Park Cancer Institute, Buffalo, NY, USA.
authors.forename: Khurshid A
authors.initials: KA
authors.lastname: Guru
authors.affiliation: Fiona Stanley Hospital, Perth, Australia.
authors.forename: Matthew
authors.initials: M
authors.lastname: Brown
authors.affiliation: King's College London, Guy's Hospital, London, UK.
authors.forename: Ben
authors.initials: B
authors.lastname: Challacombe
authors.affiliation: King's College London, Guy's Hospital, London, UK.
authors.forename: Richard
authors.initials: R
authors.lastname: Popert
authors.affiliation: Roswell Park Cancer Institute, Buffalo, NY, USA.
authors.forename: Johar
authors.initials: J
authors.lastname: Raza
authors.affiliation: Netherlands Cancer Institute, Amsterdam, The Netherlands.
authors.forename: Henk
authors.initials: H
authors.lastname: Van der Poel
authors.affiliation: Henry Ford Hospital, Detroit, MI, USA.
authors.forename: James
authors.initials: J
authors.lastname: Peabody
authors.affiliation: King's College London, Guy's Hospital, London, UK. Electronic address: prokarurol@gmail.com.
authors.forename: Prokar
authors.initials: P
authors.lastname: Dasgupta
authors.affiliation: King's College London, Guy's Hospital, London, UK.
authors.forename: Kamran
authors.initials: K
authors.lastname: Ahmed
mesh_terms: D001315:Australia; D002983:Clinical Competence; D003479:Curriculum; D004503:Education, Medical, Graduate / Q000379:methods*; D004521:Educational Measurement / Q000379:methods*; D004522:Educational Status; D005060:Europe; D006801:Humans; D059032:Learning Curve; D016014:Linear Models; D008137:Longitudinal Studies; D008297:Male; D008611:Mentors; D015999:Multivariate Analysis; D011446:Prospective Studies; D011468:Prostatectomy / Q000009:adverse effects / Q000193:education*; D015203:Reproducibility of Results; D065287:Robotic Surgical Procedures / Q000009:adverse effects / Q000193:education*; D013647:Task Performance and Analysis; D013663:Teaching / Q000379:methods*; D014481:United States
keywords: Assessment; Learning curve; Patient safety; Robot-assisted radical prostatectomy; Training