**5. Training in renal cancer surgery**

With substantial progress having being made in surgical simulation, the next challenge is formally integrating this into surgical training programmes. At present, access to simulation is often limited and certainly is not routinely incorporated into trainee assessment and technical skill development [59]. The learning curves for minimally invasive renal cancer surgery and in particular partial nephrectomy are well documented, and subsequently complications early in the surgical experience are more likely [43]. Progressing training surgeons along the learning curve in the safety of the simulation environment has obvious benefits to patient outcomes. Simulators can also be utilised at the convenience of the trainee accommodating theatre and on-call commitments and local work-time directives. Furthermore, multiple studies have demonstrated the positive attitude of trainees towards simulation with benefits reported in learning anatomy, procedural steps, skill acquisition and confidence for subsequent performance in the operating theatre [19].

At completion of the programme, mentors have a duty of care to the public to ensure trainees are competent. Accreditation of robotic programmes is not uniform, and formal assessment of the trainee on completion of many fellowships is not performed. Through the centralisation of programmes such as ERUS Robotic Curriculum, trainees can be assessed against a benchmark for safety and surgical quality. At a minimum, trainees should document the completed steps of procedures and meet minimum caseload requirements that correspond to the estimated learning curve for that procedure [64]. Outcome measures are a useful surrogate marker of

**Figure 1.** Proposed pathway for robotic training (reproduced with permission from BAUS robotic curriculum) [62].

Simulation and Training in Kidney Cancer Surgery http://dx.doi.org/10.5772/intechopen.85683 85

Robotic surgery is set to become even more widespread as new competitors enter the market and the demand for training will subsequently increase [65]. Surgical simulation will no doubt play a critical role meeting this demand, and an increase in the commercial availability of new platforms is anticipated. The ultimate simulation platform would be high-fidelity, low cost, readily available and translate to improved performance in the operating theatre. The validation process for new developments needs to be robust as resources are finite, and training time needs to be optimised. Even with the recent advancements in simulation, only limited

surgical quality, and for RAPN, these are shown in **Table 3** [64].

**Quality indicator Proposed standard**

**Table 3.** Proposed standards for outcomes on completion of robotic training.

Operative time <200 min Warm ischaemia time <25 min Estimated blood loss <150 mL Complication rate <15%

**6. Future directions**

An ideal training programme needs to match the trainee with appropriate levels of simulation and operating theatre exposure [60]. Initially, trainees should acquire basic skills on lower fidelity VR simulators, with higher fidelity bench models and whole procedure simulation on live animals or human cadavers introduced with subsequent progression [10]. Advancement through simulation platforms should be coupled with, or followed by, a modular training programme for live operative cases. Modular training involves the breakdown of a procedure into sequential steps of increasing difficulty. Novice trainees begin with a period of observation and assistance and subsequently progress through each graded step of the procedure [61]. Under this structure, a whole procedure shall only be attempted once a trainee has individually mastered all steps of the procedure.

The European Association of Urology (EAU) Robotic Urology Section (ERUS) training curriculum has been endorsed by British Association of Urological Surgeons (BAUS) and incorporates such an approach (**Figure 1**) [62]. This programme has already been validated for robotic-assisted radical prostatectomy [63].

#### Simulation and Training in Kidney Cancer Surgery http://dx.doi.org/10.5772/intechopen.85683 85

**Figure 1.** Proposed pathway for robotic training (reproduced with permission from BAUS robotic curriculum) [62].


**Table 3.** Proposed standards for outcomes on completion of robotic training.

At completion of the programme, mentors have a duty of care to the public to ensure trainees are competent. Accreditation of robotic programmes is not uniform, and formal assessment of the trainee on completion of many fellowships is not performed. Through the centralisation of programmes such as ERUS Robotic Curriculum, trainees can be assessed against a benchmark for safety and surgical quality. At a minimum, trainees should document the completed steps of procedures and meet minimum caseload requirements that correspond to the estimated learning curve for that procedure [64]. Outcome measures are a useful surrogate marker of surgical quality, and for RAPN, these are shown in **Table 3** [64].
