title: Modular Training for Robot-Assisted Radical Prostatectomy: Where to Begin?
abstract: OBJECTIVE
  Effective training is paramount for patient safety. Modular training entails advancing through surgical steps of increasing difficulty. This study aimed to construct a modular training pathway for use in robot-assisted radical prostatectomy (RARP). It aims to identify the sequence of procedural steps that are learnt before surgeons are able to perform a full procedure without an intervention from mentor.
  
  
  METHODS
  This is a multi-institutional, prospective, observational, longitudinal study. We used a validated training tool (RARP Score). Data regarding surgeons' stage of training and progress were collected for analysis. A modular training pathway was constructed with consensus on the level of difficulty and evaluation of individual steps. We identified and recorded the sequence of steps performed by fellows during their learning curves.
  
  
  METHODS
  We included 15 urology fellows from UK, Europe, and Australia.
  
  
  RESULTS
  A total of 15 surgeons were assessed by mentors in 425 RARP cases over 8 months (range: 7-79) across 15 international centers. There were substantial differences in the sequence of RARP steps according to the chronology of the procedure, difficulty level, and the order in which surgeons actually learned steps. Steps were not attempted in chronological order. The greater the difficulty, the later the cohort first undertook the step (p = 0.021). The cohort undertook steps of difficulty level I at median case number 1. Steps of difficulty levels II, III, and IV showed more variation in median case number of the first attempt. We recommend that, in the operating theater, steps be learned in order of increasing difficulty. A new modular training route has been designed. This incorporates the steps of RARP with the following order of priority: difficulty level > median case number of first attempt > most frequently undertaken in surgical training.
  
  
  CONCLUSIONS
  An evidence-based modular training pathway has been developed that facilitates a safe introduction to RARP for novice surgeons.
authors.affiliation: King's College London, London, United Kingdom.
authors.forename: Catherine
authors.initials: C
authors.lastname: Lovegrove
authors.affiliation: King's College London, London, United Kingdom; MRC Centre for Transplantation, Guy's Hospital, London, United Kingdom. Electronic address: kamran.ahmed@kcl.ac.uk.
authors.forename: Kamran
authors.initials: K
authors.lastname: Ahmed
authors.affiliation: Department of Urology, University of Padua, Padova, Italy.
authors.forename: Giacomo
authors.initials: G
authors.lastname: Novara
authors.affiliation: Department of Urology, Roswell Park Cancer Institute, Buffalo, New York.
authors.forename: Khurshid
authors.initials: K
authors.lastname: Guru
authors.affiliation: Department of Urology, OLV Clinic, Aalst, Belgium.
authors.forename: Alex
authors.initials: A
authors.lastname: Mottrie
authors.affiliation: MRC Centre for Transplantation, Guy's Hospital, London, United Kingdom.
authors.forename: Ben
authors.initials: B
authors.lastname: Challacombe
authors.affiliation: Department of Urology, Netherlands Cancer Institute, Amsterdam, The Netherlands.
authors.forename: Henk Van
authors.initials: HV
authors.lastname: der Poel
authors.affiliation: Department of Urology, Henry Ford Hospital, Detroit, Michigan.
authors.forename: James
authors.initials: J
authors.lastname: Peabody
authors.affiliation: MRC Centre for Transplantation, Guy's Hospital, London, United Kingdom.
authors.forename: Prokar
authors.initials: P
authors.lastname: Dasgupta
mesh_terms: D001315:Australia; D002983:Clinical Competence; D004503:Education, Medical, Graduate / Q000379:methods; D005060:Europe; D005257:Fellowships and Scholarships; D006801:Humans; D038622:Internationality; D008137:Longitudinal Studies; D008297:Male; D011446:Prospective Studies; D011468:Prostatectomy / Q000193:education* / Q000379:methods; D065287:Robotic Surgical Procedures / Q000193:education* / Q000379:methods; D000066908:Simulation Training / Q000379:methods*; D006113:United Kingdom; D014572:Urology / Q000193:education
keywords: Interpersonal and Communication Skills; Medical Knowledge; Patient Care; Practice-Based Learning and Improvement; Professionalism; RARP; modular training; safety; surgical training