The field of urology holds a rich history of embracing new technologies to enhance patient care. Since its early adoption, the utilization of robotic platforms has experienced exponential growth, now constituting the majority of prostatectomy and kidney procedures.¹ The abbreviated learning curve compared to laparoscopic techniques has contributed to this expansion. This widespread adoption underscores the need for an expanding integration of robotics into urologic training. However, the optimal strategies and training framework remain unclear.

Urologists’ increasing familiarity with robotics and the growing availability in the community have impacted case volumes at large academic centers, thus affecting the resident experience. As such, trainees must focus on demonstrating familiarity with the robotic platform and the surgical procedure before making any incision to maximize their robotic training. Before accessing the control console, trainees must be able to demonstrate a strong foundation in the procedural steps, proficiency in robotic instrument movements, and an understanding of tissue planes and tissue handling.

One of the greatest challenges to complex surgical skills development in the current era is the limited exposure to training opportunities within a 5-year residency timeframe. There are many contributing variables that go beyond work hour limitations. There are now more attendings, all of whom use a different technique. There is a growing list of robotic procedures to learn. Robotics cases are now decentralized, resulting in decreased case volumes as robotic cases are now being done routinely at small community hospitals. Many urology programs have expanded, leading to more residents to train and in many programs, more residents to train per year. There are a multitude of factors that may play a role in dilution of the training opportunities in the current era, depending on where one may train.

Trainees’ understanding of the surgical steps is developed both in and out of the operating room. At our institution, we place a strong emphasis on surgical video review and bedside assisting starting at the junior resident level. Video recording during minimally invasive procedures allows for review postoperatively and recorded cases should be routinely available at training programs. Compared to conventional training, residents who received video-enhanced surgical training with preprocedural instructional videos displayed higher overall surgical performance.² Video review provides visual aids to enhance the learning process as trainees better understand the steps of the procedure. Furthermore, it allows for an understanding of the nuances of each surgeon, enabling anticipation during surgery. Reviewing complications helps to learn from others’ mistakes. The future in artificial intelligence–driven video capture and video analysis will certainly enhance the role of video in training programs.

Bedside assisting is the trainees’ first hands-on experience with the robotic surgical platform. It provides the opportunity to become an active participant in the procedure and apply what they learned during their video review without the demands of being the primary surgeon. Here, trainees at the bedside learn to safely gain abdominal access to establish pneumoperitoneum, consider appropriate port placement, and troubleshoot common issues during a robotic surgical procedure. As robotics has emerged as the preferred minimally invasive surgery approach, trainees must find opportunities to build and maintain their laparoscopic skillset. The bedside experience is critical as they are expected to apply countertraction and optimize exposure for the console surgeon. The priority of junior residents is maximizing the experience at the bedside, rather than obtaining console time which is often low yield and prolongs patient anesthesia time. In fact, studies report the correlation with robotic bedside experience and improved console performance, compared to bedside-naïve trainees.³

While juniors grow their bedside surgical skills, trainees should simultaneously familiarize themselves with the console through the utilization of a robotic simulator. The simulator provides virtual reality exercises to develop the technical movements of the robotic instruments, such as camera tracking, clutching, and suturing. Studies analyzing the kinematic movements of robotic instruments have reported fewer unnecessary maneuvers in more expert surgeons and have even correlated expert movements with improved outcomes following robotic radical prostatectomy.⁴ While no standardized curriculum has been reported, trainees at our institution are expected to complete the virtual reality simulator training modules under their login credentials.

The third proficiency, tissue handling and tissue planes, is arguably the most difficult to develop. As a senior or chief resident in our program, one is expected to integrate all the prior learned experiences and learn to mimic the skills demonstrated by their various attendings. While video review and bedside assistance contribute to the development of tissue plane identification, tissue management requires hands-on console experience. Cadaver or animal simulation labs offer the closest experience to live patient tissue. However, these simulation labs are often associated with high costs and regulatory obstacles, which have promoted the use of alternative training methods. Recent studies reported the use of 3D printing of anatomic organs equipped with perfusion for procedure simulation. Utilization of these models may eliminate the early cases of the learning curve and hasten the time to the mastery level.⁵

While emphasis is placed on resident robotic surgical education, patient safety should always remain a top priority. The completion of these necessary proficiencies demonstrates understanding of the robotic platform, commitment to improvement, and instills confidence in the supervising physician of trainees’ preparedness for advancement. Robotic surgery offers an opportunity for trainees to participate and improve both in and out of the operating room. With limited training opportunities due to the changing landscape described above, programs need to understand the factors limiting their trainees’ experiences and develop institution-specific strategies to increase training opportunities. At the same time, trainees must continue to take initiative to prepare and maximize their own personal opportunity.