EAU 2019: Definition of a Structured Training Curriculum for Robot-Assisted Radical Cystectomy: A Delphi-Consensus Study Led by the ERUS Educational Board

Barcelona, Spain (UroToday.com) Robot-assisted radical cystectomy (RARC), with or without intracorporal urinary diversion, continues to increase in usage as urologists become more comfortable with the robotic platform. With the recent RAZOR trial1 demonstrating non-inferiority to open cystectomy with regards to 2-year progression-free survival, more and more surgeons (with increased access to the robot and greater experience in prostatectomies/kidney cases) may begin to utilize the robot for RARC. While the key steps for robotic prostatectomy are relatively well established, the authors of this papers, all high volume robotic surgeons with strong experience in RARC, feel these trends call for the development of a structured training curriculum for RARC based on simulation activity, clinical training, and non-technical skills, with the aim to improve patient safety during the RARC learning curve.

To do so, they utilized a modern modified Delphi consensus process, which is composed of 3 rounds, to develop the structure of the curriculum. A web-based survey based on the available evidence was delivered to a panel of 26 experts in the field of RARC. Experts were selected according to surgical, research experience and expertise in running training courses in RARC field. To date, the 1st round has been completed. Consensus for the responses to the first round was defined as ≥80% agreement between the responders. Frequency and proportions were used to describe the outcome of the survey.

In the first round, 25 out of 26 (96.2%) experts completed the survey. The consensus was reached in multiple areas, which are detailed in Table 1 below.
Robot-assisted radical cystectomy

The structure of the simulation-based training (Figure 1A) and the modular console training (Figure 1B) were defined.
EAU 2019_modular console training_2.png

Unfortunately, as of yet, no agreement was yet reached on the number of cases required to complete some of the steps that defined the modular training (Figure 1B) – specifically harvesting the bowel segment and the ileo-ileal anastomosis, and ureter-ileal anastomoses, both of which are rated 5/5 in terms of complexity. They also could not yet agree on number of cases needed for the anterior dissection of the prostate (similar to the prostatic dissection) and the stoma creation.

Eventually, once a consensus is reached, this protocol can be implemented in the various schools of training that are arising, including the O.L.V. Vattikuti Robotic Surgery Institute (ORSI), a multidisciplinary school of robotic surgery founded by Dr. Mottrie in 2010.

Presented by: Paolo Dell'Oglio, Onze Lieve Vrouw Hospital, Orsi Academy, Dept. of Urology, Aalst, Belgium

Written by: Thenappan Chandrasekar, MD (Clinical Instructor, Thomas Jefferson University) (twitter: @tchandra_uromd, @JEFFUrology)  at the 34th European Association of Urology (EAU 2019) #EAU19 conference in Barcelona, Spain, March 15-19, 2019.

References:
  1. Parekh DJ, et al. Robot-assisted radical cystectomy versus open radical cystectomy in patients with bladder cancer (RAZOR): an open-label, randomised, phase 3, non-inferiority trial.
    Lancet. 2018 Jun 23;391(10139):2525-2536.
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