Since the feasibility and safety of robotic prostatectomies were reported in the early 2000s,¹ applications of the robotic platform in urologic surgeries have drastically increased. The robot is now routinely used in many adult urologic procedures, and its application is steadily rising in pediatric urology as urologists overall are becoming more comfortable and confident with this minimally invasive approach. For many cases, robot-assisted approaches have been reported to be as effective as open procedures and offer additional benefits including decreased lengths of stay and reduced postoperative pain.² There is no question that robot-assisted urologic procedures are here to stay.

Despite the many benefits of the robotic approach, one critical difference compared to open and laparoscopic surgeries is that the surgeon is not scrubbed at the patient’s side. The surgeon must be able to manage the patient from the console by providing clear instructions to the bedside assistant or surgical technician in cases of uncontrolled bleeding. Should acute compromise occur, a quick decision must be made to emergently undock and convert to open surgery as necessary. Although rates of open conversion are relatively low, ranging from 0.1% to 6%,³ these processes can be stressful and chaotic. Success requires effective communication, coordinated teamwork, and strong leadership.

The Role of Simulations

Incidences of emergent conversion are rare, so learning what to do and how to react in these high-stress situations through exposure is not a viable option. Certainly, no one wants these emergent situations to become a norm for operating room (OR) staff and surgeons to get comfortable at the risk of patient safety. Yet, without a doubt, preparedness is necessary to prevent potentially catastrophic outcomes. Herein lies the role of multidisciplinary, team-based, in situ simulations.

Preparing for the worst case scenario through simulations is not a new concept. It is widely applied in aviation training and well incorporated into residency training by our colleagues in anesthesia, trauma, emergency medicine, and critical care.^4,5 The refinement of soft skills including leadership, teamwork, and closed-loop communication through simulation has been found to be critical to success in cardiopulmonary resuscitations and these are now incorporated into advanced life support courses.⁶ Simulations in emergent robot to open conversions can offer similar benefits.

Establishing Robot to Open Conversion Simulations

To better prepare our OR team for these rare but potentially disastrous scenarios, we began developing an institutional robot to open conversion simulation program in 2020. A conversion protocol was created by a multidisciplinary team which included 6 pediatric urologists, a pediatric anesthesiologist, a senior urology surgical scrub technician, and 3 OR nurses (Figure). The protocol details key communication and action items the team deemed to be critical in the conversion process. To increase fidelity of the experience, a low-cost, remote-controlled model that simulates sudden hemorrhage was used. This model allows the simulation director to initiate “bleeding” at an unexpected time to prompt the OR team to go through the exercise of conversion. As the rest of the team are unaware when bleeding will occur, this simulation design facilitates an element of shock that the team may experience in these unexpected scenarios. The stakeholders underwent 3 simulations over the course of 2 years and iteratively refined the protocol and the simulation model after each session. Two team members trained in simulation facilitation led discussions during these sessions to ensure effective pre- and postsimulation briefings. These simulations are now being conducted to train OR staff and trainees involved in robotic cases. Survey results on participant confidence and comfort with the process as well as times for conversion are pending.

Figure. Robot to open conversion protocol. Schematic detailing communication and action items for each team member when assessing the need for conversion and during conversion from robotic to open surgery for acute hemorrhage. As the process of conversion may be stressful and fast reaction times are necessary, the protocol provides a guide of critical elements to be considered at a time when the initial shock of the situation may cloud judgment and delay effective communication and management. OR indicates operating room; TBV, total blood volume.

Challenges

It is important to note that our effort in establishing this simulation is not unique. Reports of similar simulations and protocols have been published.^7-9 Yet, these simulations are not widely prevalent and are not routinely incorporated into OR staff or residency training. Furthermore, there are limited reports, if any, on pediatric robot to open conversion. Establishing these simulations can be time-consuming. Developing a high-fidelity simulation that offers a meaningful experience and safe environment for the participants requires extensive preplanning and multiple trials to iteratively refine the process. Support from institutional simulation centers and identifying champions in each discipline are critical. Gathering a multidisciplinary group of surgeons, anesthesiologists, OR nurses, trainees, and scrub technicians during working hours in an open OR for an hour requires departmental and OR leadership support. The process can also be costly if an expensive model is repeatedly used, so balance between model fidelity and cost must be weighed.

Future Directions

Despite the potential barriers to establishing these simulation programs, these efforts are important in improving patient safety as robotic urologic procedures become the norm. This may be especially important in pediatric robotic cases where acceptable margins of error are narrower. Simulation education is slowly gaining traction within our field, and with the support from institutional leadership and simulation centers, many of the previously noted barriers can be easily traversed. Multi-institutional collaborative efforts would be instrumental in increasing prevalence of these programs and would be informative in establishing standardized protocols.

Acknowledgments

We thank the following individuals for their contributions to this effort: Charles Ammah; Linda A. Baker, MD; Cristina Garofalo, RN; Jennifer Longoria, RN; Chelsea Manzano, RN; Paige Plattner, RN; Bruce J. Schlomer, MD; Irina Stanasel, MD.