**3. Financial implications**

Allowing robotic technologies into the operating room can provide significant advantages. For example, the robot can provide a precise translation of the surgeon hand movements, through the robotic instruments during the actual surgery. Importantly, the robot facilitates surgeons without advanced laparoscopic skills to perform complex surgeries with short/limited training. In addition, the robotic technology has increased the types of surgeries undertaken. The endo-wristed tools with motion scaling (avoids tremor) and 3D zoomed operative fields promote the ability of the surgeon to undertake microdissection and intra-abdominal

The rapid rise of robotic technologies has allowed more complex reconstructive surgeries to be performed even in children [4]. Instruments such as 3–5 mm trocars have aided robotic surgery in children. Importantly, single-port and multi-arm (non-central) platforms are becom-

As this advancement continues, the financial and clinical issues surrounding the employment of a robotic system within any hospital require planning. This planning starts from identifying the finances (business planning) through to purchase, and identifying key members of the team who will provide training to the team as a whole and oversee clinical and financial

Surgical outcomes are determined by high levels of competence of the team and optimal team working. Therefore, surgeons rely on the team. Robotic surgery is no exception, particularly as the surgeon works at a console and therefore relies on the team which includes the bedside assistant who performs important tasks at the patient bedside. Educating the robotic (or other) operating room team of nurses, anesthesia staff, and bedside assistant is crucial for patient outcome success. It is crucial that the team and team leader communicate with other staff and mentors to provide the support and guidance needed during the train-

Administrators and surgeons must work together to define the needs of the hospital, when developing a robotic programme. A surgeon with administrator can develop a programme which is often more patient-centric and deployable. Interestingly, robotic use can improve patient referrals, which is often the reason the administrators are supportive. The best situation is for the surgical teams and administrators to co-plan and co-deliver robotics within a

In a teaching hospital, teams generally work cohesively, allowing intellectual debate, particularly around new technologies such as robotics. They usually find funding through academic pathways or sizeable donors. This is important for training the next generation of surgeons, and improving our understanding of where robotic surgery can take us. As robotics develop in this way through research and resident training, these programmes can be delivered into more peripheral centres. Once this occurs, a close "hub-and-spoke"

**2. Clinical to hospital administration collaboration**

suturing with great accuracy [3].

224 Evolving Trends in Kidney Cancer

ing commercially accessible.

governance of the system.

hospital or strategic health partnership.

ing stage.

Currently, the average cost of the da Vinci robotic system is \$1.4–1.9 million, and the annual maintenance is approximately \$240,000. Link et al. [5] suggest an increase in robotic surgery volume which can counter for the depreciation and maintenance costs. They showed that robotic pyeloplasty (RLP) is more expensive than laparoscopic pyeloplasty, if performed by a surgeon competent in intracorporeal suturing. The study also concluded that the combined longer operative time and substantial expense for robot depreciation and consumables made RLP a much more expensive procedure (2.7 times more than laparoscopic pyeloplasty). Importantly, increasing the number of robotic procedures can neutralize the cost imbalance, such as performing 10 robotic prostate surgeries per week (cost neutral compared to open prostate surgery) [6].

These debates are important to be aware of, but the main issues are the steep learning curve for the average surgeon using pure laparoscopy and thus greater risk to the patient. The robotic platform offers a truncated learning curve, and therefore the financial burden becomes more acceptable. A further point is that, as the robotic surgeons gain more experience, the robotic

**Figure 1.** Robotic Urology Surgery Training Centre Accreditation (European) and Royal College of Surgeons of England.

operative times diminish considerably and in many institutions may be quicker than the equivalent operation performed laparoscopically. The economic arguments are not therefore constant or static but an ever-changing field.

Robotic (ZEUS; Computer Motion) and laparoscopic instrument learning curves were compared within inanimate models and showed a greater learning curve with robotics [10]. Another animal study showed that multiple surgical disciplines in a "near hospital operating room" environment with same-member healthcare teams improved their average set-up times by 30%, each time they prepared the robot [11]. In addition, the console operators improved their operation times by over 20% each time they practiced. They showed that in-house training saved them significant monies (approximately \$52,895) and improved operative and set-up times by 40–50%.

Robotic Surgery and Successful Set-Up: A Stepwise Approach

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Curiosity and commitment to robotics are helpful when motivating a team. However, it helps to have the support and enthusiasm of your hospital, including the management through

The primary group to get on board are the surgeons committed to robotics. Importantly, robotic surgery programmes develop purposefully and often slowly. Each step requires audit cycles, critically analysing the robotic team performance and not simply the surgeon. Team leaders in the operating room should be empowered to feedback performance values at each step of the process for safe and effective outcomes. Once the team engages in this process, it

Training within a team is an early and crucial step. Using a standard learning tool such as an objective-based curriculum, which is visual and live, allows for the best results. This should allow foundation building from experiences, in a stepwise manner (modular). For the more specialized team member requiring understanding of specific operative nuances, a more spe-

The generic robotic team should begin the process by understanding the set-up, draping, and both electrical and mechanical troubleshooting. These basic steps would suffice to then return

**6. Training the robotic surgical team**

is the most rewarding experience.

cialized skill set is needed [12].

**Figure 2.** A happy and supportive robotic team is essential!

your clinical colleagues and team leaders (**Figure 2**).

Importantly, once the hospital has agreed that a budget is available and a sensible financial plan is in place, the early adopters of the robotic technology need to be identified and offered a curriculum-based training programme [7] (**Figure 1**).
