The Future of Surgical Skills Evaluation: What Is on Your Wish List?

Mordechai DuvdevaniIsrael Moderator

John DavisUnited States Speaker Open Surgery Training: Is It Necessary in the Era of Robotics?Open surgery training in the era of robotics may or may not be a training environment that urology has control of, given worldwide access to robotic or at least laparoscopic techniques and strong patient preference. There may be some applications where a given experienced urologist can prefer open over minimally invasive surgery (MIS), such as radical cystectomy, or indications possibly outside of MIS feasibility such as large renal tumors with caval thrombus. Specific to training and expertise, there are 3 principle features of surgical skills desired: 1) knowing ideal exposure, 2) recognition of surgical planes, and 3) knowing anatomy before it can be seen. Although some trainees may only see MIS for certain indications, open surgery may expedite the process. There are no human studies identified on the topic, but a skills lab study was instructive (Farah, J Surgical Education 2023) showing that interns with open and MIS training performed higher comparing pre-intern to post intern bootcamp skills. The benefits of a solid training pathway including open experience are to move trainees towards the faster-to-progress part of the learning curve such that the attending can offer a safe training environment while moving the case along efficiently.The Future of Surgical Skills Evaluation: What Is on Your Wish List?Surgical skills training vary significantly by region with some systems putting trainees on a timed set of years, while others apprentice trainees until meeting a threshold for skills. Early training assessments were basic timed events with qualitative scores (subject to strong attending selection for success). Trainees should experience and/or study the key pitfalls to avoid and performance goals. Surgical simulation can be highly useful, but tend to improve only certain skills and not full case needs. Updated simulation moves from digital to hands on surgical models and may move the needle towards human experience. Training can be augmented with descriptors of surgical gestures and measuring which ones are most effective. The experience for the trainee is often depicted as an "autonomy gap" whereby the training desires to have case control, possibly before they are ready. Progression can be measured by descriptors of performance from assistance through full performance without coaching. The next frontier will be artificial intelligence guided measurement where specific performances can be characterized and diagnosed for success. My ultimate wishlist would be for methods to correlate skills to outcomes, optimized curricula, and a specific pathway to correct underperformance.Tips and Tricks in Challenging Cases of Robotic Radical ProstatectomyThere are many specific challenges with robotic radical prostatectomy (RARP) that can be described and illustrated--the most 5 common are 1) difficulty access, 2) obesity, 3) pubic arch interference, 4) anatomic challenges, and 5) reconstruction challenges. In this video sample, we demonstrate 2 challenges: obesity requiring a pelvic lymph node dissection and significant pelvic de-fatting to identify the proper surgical landmarks. Next a massive sized prostate that has had a partial transurethral resection--together presenting challenges with landmarks, a difficult bladder neck to diagnose, and final reconstruction challenges.