The rise of robotic-assisted surgical systems (RASS) occurred as researchers and surgeons sought to overcome limitations associated with older laparoscopic procedures—namely, a large physical burden on surgeons, limitations in visualization of the surgical field, and fewer degrees of freedom than enjoyed by RASS.^1-3 The da Vinci Surgical System, one of the most well-known RASS approved by the Food and Drug Administration in 2000, has become a part of many urologists’ daily practice. Between 2003 and 2015, the use of robotic-assisted surgery for radical nephrectomy procedures in the United States increased from 1.5% to 27%.⁴ Indeed, for the past 20 years, Intuitive Surgical Inc—the manufacturer of the da Vinci—has dominated the surgical robot market. Although questions have been raised about cost burdens of the surgical system and outcomes data is inconclusive about its benefits in some procedures,^5-7 it is clear this technology will remain an essential part of urological training and practice moving forward.⁸ Rapid advancements in robotic surgery are occurring at an incredible rate with the introduction of new systems like the da Vinci single-port robot system.⁹

As with many new technologies, the swift adoption of robotic surgery has led to its increased use—not only by urologists in practice but also by residents in training. In a study analyzing the 89,199 major cases recorded by 209 urology residency graduates, researchers found the median proportion of robotic cases increased in reconstruction (4.7% to 15.2%), oncology (27.5% to 54.2%) and pediatrics (0% to 10.9%) between 2011 to 2017.¹⁰ However, the rapid implementation of robotic surgeries has potentially bypassed the development of an intentional, resident-specific robotic curriculum. Residency training has not necessarily caught up to the explosion in robotic volume, as 64% of surveyed urology chief residents reported they would be unable to perform robotic partial nephrectomy as first surgeon and 61% of respondents endorsed lack of confidence in performing robotic radical prostatectomy.¹¹

Difficulties in robotic surgical curricula can be traced back to the first modules made to help surgeons. The earliest learning modules about robotic surgery were developed by Intuitive Surgical for expert surgeons seeking to use this new technology.¹² In response, residency programs around the country have sought to create individualized programs to ensure residents are comfortable with this technology. Still, these individualized programs have struggled to adequately address training with this new technology. In a study of robotic training programs in general surgery, Green et al found even the newest training programs fail to account for residents’ lack of surgical experience, struggle to clearly define intraoperative components, and lack agreements on resident operative autonomy.¹² Additionally, training programs often focus more on technological components of the robot as opposed to cognitive pieces of the surgery.¹² It is also timely to highlight the strain on educators who have to train residents in an increasingly time- and cost-sensitive health care environment. Attending surgeons, more than ever, will have to find the right balance between training residents adequately on the robot while also attempting to improve outcomes, reduce costs, and shorten operative time, which increases in robotic compared to open procedures.^13,14

Like general surgery, the field of urology still lacks a unified training curriculum and clearly defined guidelines for robotic surgery. While the AUA has created an introductory standard operating procedure highlighting a credentialing process for residents training in robotic surgery, it lacks the detail required by a more structured curriculum.¹⁵ These guidelines state residents should “complete a minimum of 20 cases; these can be pediatric and/or adult robotic surgical cases, but the trainee must have console time for a key portion of the procedure with at least 10 cases” and that “a curriculum involving exercises using virtual reality simulators is recommended [to train residents]”.¹⁵ Case logs from the Accreditation Council for Graduate Medical Education in 2021 to 2022 showed 90% of urology residents were the lead surgeon in 70 robotic cases, with 10% acting as the lead surgeon in more than 275 robotic cases.¹⁶ Thus, these guidelines, while valuable, do not accurately capture the volume of robotic surgery in urology residencies today. Additionally, while Intuitive created the Intuitive Academy as a program for residents and fellows that provides webinars and hands-on training to users, it is unknown to what extent urology programs and residents use this material.

Increased standardization would help to address many problems including improving nontechnical skills, which are just as vital as knowing the technical steps of the operation. Theoretical knowledge, teamwork, communication, and decision-making are key components that are often not formally addressed in today’s robotics training programs.¹⁷ Most programs have developed custom in-house curricula, and the best practices of successful programs must be identified to improve overall medical education. Notable efforts to improve robotic training have included investment in simulation centers, 3D-printing of operative surgical models, and standardized feedback about resident operative performance on the robot.¹⁸ Lastly, a more clearly defined case volume can allow for better determination about the mastery of residents of certain procedures. Herrell and Smith identified the learning curve for a robotic-assisted laparoscopic prostatectomy to be between 150 and 250 cases—further research on other robotic procedures can more fully define the adequate volume necessary for the certification of residents across various urologic procedures.¹⁹ Improvements to AUA guidelines might even include common robotic procedures—like cystectomies, prostatectomies, and nephrectomies—and the minimum recommendations suggested for proficiency.

Robotic surgery will remain a core component of urological surgical education in the future. Although great advancements have been made in the rapid adoption of this technology, there is still work to be done. While robotic surgery is only one part of a well-rounded urological residency, the volume of robotic surgery is increasing, and with it comes the critical need to ensure a more uniform education. Prospective urologic trainees should consider if programs offer a comprehensive and standardized curriculum for robotic training, and trainees at all levels should continue to advocate for progress with curricular development in this space.