AUA 2013 - Session Highlights: Point-Counterpoint: Simulation for robotics - Compulsory or optional

SAN DIEGO, CA USA ( - Dr. Christopher Kane, the moderator of this plenary session, opened the discussion by highlighting that robotic surgery has emerged as a new technology over the last decade and has brought with it new challenges, particularly in terms of teaching and training.

To help overcome these challenges, robotic courses, virtual simulators, and a dual-console robotic platform have been introduced. To date, robotic courses have found success around the world, allowing participants to implement robotic programs at their institutions after completing a course, and typically with the help of an on-site proctor. Simulators have also found success as part of robotic education curriculums. In fact, there are several simulators currently on the market that have proven to be a valid option for training, especially for the novice trainee.

auaDr. Kane stressed the importance of training in the lab for skill acquisition prior to first performing the procedure. All procedures might have human error, and practice is fundamental to decrease these errors. This can be difficult for residents and other trainees in the US in light of the 80-hour work-week limitation. Additionally, such training might take the residents away from other critical types of learning.

Dr. Kane also highlighted that the cost of perioperative complications can increase hospital costs upwards of 600%, further supporting the role for comprehensive robotic training to ensure all surgeons have the necessary skills to achieve success.

Although courses, simulators, and the dual console have been successfully introduced, the data remains relatively scarce concerning their exact role in training. The aim of the point-counterpoint was to discuss if simulation for robotic surgery should be compulsory or optional.

Dr. Chandru P. Sundaram, who debated in favor of compulsory simulation for robotics training, started his argument stating that the discussion shouldn’t be whether robotic simulation is compulsory or optional, but, rather, what kinds of simulation we should be doing.

Presently, three types of training models exist: inanimate, porcine/cadaver, and robotic simulators. Dr. Sundaram focused on the role of robotic virtual-reality simulators.

One of the first robotic simulators was the Mimic dv trainer. Early validation studies demonstrated that this type of training had good validity both for content and reality. Currently, there are four VR robotic surgical simulators available: RoS, dV-Trainer, SEP Robot, and the da Vinci Skills Simulator. All of the systems have basic skills training and exercises, with performance analysis and metrics software. Each system is represented in the literature, and all possess varying degrees of face, content, and construct validity. Most importantly, there have been a few recent studies that support that simulation training can decrease perioperative complications.

Dr. Sundaram believes the real benefit of virtual reality simulation is its potential to standardize surgical training for robotic surgery. Furthermore, virtual reality simulation for robotics can be used for compulsory accreditation for surgeons and to help teach tips and tricks. Subsequently, these measures might then result in fewer complications and decreased perioperative costs. He concluded his lecture by asking, “Who would enter an aircraft knowing that the pilot hadn’t gone through simulation training?”

Next, Dr. Robert B. Nadler, argued that simulation for robotics should be optional. He began by citing three factors that are limitations to robotic simulation: time, cost, and lack of realism. However, Dr. Nadler was nevertheless in favor of basic simulation, agreeing that surgeons should have knowledge of the basic principles of robotic surgery and practice such principles.

First, in terms of time limitation, Dr. Nadler raised a similar concern to that identified by Dr. Kane. In the U.S., the Accreditation Council for Graduate Medical Education (ACGME) defines that residents should have a limit of 80-hours of work per week. Accordingly, robotic simulation training might take the residents away from other critical types of learning that cannot be experienced due to work hour limitations.

Second, virtual reality training costs $85,000-$100,000 per year. Additionally, the teaching institution requires an animal lab and an exclusively dedicated robotic system for training, making cost a key limitation.

Lastly, Dr. Nadler cited several studies that have concluded that simulation for robotics is not realistic and is very different from real surgery. Similarly, he mentioned several studies that have demonstrated that although simulation for robotic surgery improves tasks, it doesn’t change perioperative outcomes. In addition, he reported an AUA 2013 abstract (#1567) that showed overall poor correlation between simulation performance and operative performance.

Dr. Kane concluded the point-counterpoint debate stating that basic training is fundamental, and surgeons should be trained in the key principles of robotic surgery. However, simulation for robotics is financially expensive and residents’ training time is limited by the 80-hour work week. Further studies are needed to validate if there is any correlation between simulation and clinical performance to determine its exact role in training.

Moderated by Christopher J. Kane, MD at the American Urological Association (AUA) Annual Meeting - May 4 - 8, 2013 - San Diego Convention Center - San Diego, California USA

Chair, Department of Urology, Professor of Surgery, UC San Diego Health System, San Diego, California USA


Reported for by Samuel Juncal and Michael Ordon, MD; UC Irvine Medical Center, Orange, CA USA

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