Single Session of Robotic Human Cadaver Training: The Immediate Impact on Urology Residents in a Teaching Hospital

Abstract

Introduction and Objective:

To evaluate the immediate impact of robotic human cadaver training on the confidence with robotic surgery among urology residents.

Methods:

After a preliminary survey assessing baseline skills, our institution's urology residents attended a single session of robotic training on fresh-frozen human cadavers, supervised by staff urologists. Post-training, both the residents and the supervisors were administered a survey querying the improvement of robotic skills and the sentiments toward the cadaver laboratory compared with alternative trainings (answers were given by Likert scale: 1 = negative/5 = positive).

Results:

Twenty-two residents and five supervisors completed the surveys. Median residents' age was 32 years (IQR 29–33). Median year of residency was 4 (IQR 3–6). One hundred percent of the residents were familiar with robotics (86.4% had previous experience as bedside assistant; 90.9% have performed a median of 15 procedures at console). Post-training the residents evaluated their confidence with port placement and docking, EndoWrist^® manipulation, Camera and Clutching, Fourth Arm Integration, and Needle Control and Driving with median scores of 4 (IQR 4–5), 4 (IQR 4–5), 4 (IQR 4–5), 4 (IQR 4–4), and 4 (IQR 3–4), with significant perceived improvement in all skills (P < .045). Almost all of them (86.4%) rated the cadaver training 5. When asked about the superiority of human cadaver training with respect to the virtual simulator and the pig laboratory, residents gave median scores of 5 (IQR 5–5) and 4 (IQR 3–5). At univariate analysis, increased experience with robotics was found to be inversely associated with improvement in the “camera and clutching” skill (P < .048). The supervisors felt that human cadaver training was effective in improving the residents' robotic skills (median answer of 5, IQR 4–5).

Conclusions:

Human cadaver robotic training demonstrated great acceptability among both the residents and the supervisors. It allowed for immediate improvement of the residents' robotic skills.

Introduction

Robotic surgery use has increased exponentially over the last decade. In 2015, there were more than 650,000 procedures performed all over the world.¹ The rapid adoption and dissemination of this technology has largely occurred as a result of the perceived benefits of improved ergonomics, dexterity, safety, and ease of surgery.^2,3

Such an advance in technology has revolutionized the surgical practice with major influence on urology. Following the initial description by pioneers in this field, many established open and laparoscopic surgeons undertook robotic surgery without following a standardized, validated robotic curriculum.⁴

The need for formal assessment of competency to ensure safe and sustained growth has led various groups to propose competency-based training programs in robotic surgery. Indeed, training in the simulation laboratory is being widely adopted to enhance the performance in the operative room.^5–7

Increasing the number of virtual reality (VR) simulators, dry laboratories and animal models have been described and evaluated for simulation-based training in all aspects of urology.^8–12

However, despite their cost and the lack of availability, human cadavers have been rated to be highly effective for procedural surgical training in pure laparoscopy literature.^13,14 But to date, their use in robotic surgery has been particularly limited to experimental novel approaches by experienced surgeons.^15–17

The primary aim of the study was to evaluate the immediate impact of robotic human cadaver training on the confidence with robotic surgery among a cohort of urology residents after a single session of robotic human cadaver training. The secondary aim was to test the validity of the training day as perceived by supervising experienced robotic surgeons.

Materials and Methods

Our institution's urology residents were enrolled in a 1-day robotic cadaver laboratory offered by the Glickman Urological Institute at the Cleveland Clinic Foundation (Cleveland, OH).

The participants underwent an intensive robotic training on human cadavers under the supervision of five expert staff robotic surgeons. Three human cadavers and three respective robotic platforms were prepared with full availability of the surgical instruments for performing pelvic and kidney robotic procedures through the transperitoneal approach (see the Supplementary Data S1 and the Supplementary Fig. S1; Supplementary Data are available online at www.liebertpub.com/lap).

Residents' baseline survey

Before starting the training, the residents were asked to anonymously fill a survey with their demographic data, the residency program year, prior robotic experience (either as bedside assistant or as console surgeon, including the number of procedures performed, respectively), and previous robotic training performed (including da Vinci VR simulator and animal laboratory) (Supplementary Data S2).

Moreover, they were asked to self-assess, based on a Likert scale (1–5, where 1 was very poor/extremely negative and 5 was excellent/extremely positive), their confidence levels for each of the following da Vinci VR simulator components, namely: (1) ports placement and docking; (2) EndoWrist^® manipulation; (3) Camera and Clutching; (4) Fourth Arm Integration; and (5) Needle Control and Driving.

Residents' post-training survey

At the end of the training day the residents were readministered a survey and were asked to reassess their confidence using Likert scales for each of the abovementioned da Vinci VR simulator components (Supplementary Data S2). Their answers were evaluated to determine if any improvement in their confidence took place.

Specifically for the purposes of the study, the post-training survey asked residents about their impressions regarding the training on the human cadaver itself and in comparison to other training modalities, namely training on the da Vinci VR simulator, training on the animal model, and “training” on human patients.

Supervisors' post-training survey

In parallel, at the end of the training, the supervisors who participated in the training day were administered a survey to rate the improvement of the residents with the abovementioned da Vinci VR simulator components (Supplementary Data S3). Moreover, they were asked to rate how the human cadaver training was compared to other methods.

Statistical analysis

Descriptive statistics was performed for the available variables. Categorical variables were reported as frequency and percentage; continuous variables as median and interquartile range (IQR) or mean and standard deviation, as appropriate. Median values among groups were compared using the sign test.

Univariate regression analysis was performed looking for predictors of improvement after the training (continuous predictors: age, number of procedures performed as bedside assistant, and number of procedures performed as console surgeon; categorical predictors: residency program year, previous da Vinci simulator, previous pig laboratory, and >15 procedures performed as console surgeon). Statistical significance was set at P < .05. The statistical analysis was carried out using “Statistic” 8.0 software (StatSoft, Tulsa, OK).

Results

Residents' profile and background

Twenty-two urology residents participated in the robotic human cadaver training and agreed to fill the precourse and end-of-course surveys.

The median participant age was 32 years (interquartile range, IQR 29–33). Median residency program year was 4 (IQR 3–6).

The majority of the respondents (86.4%) had previous experience with bedside assistance during robotic procedures, with a median of 50 procedures performed (IQR 20–127). The same was true regarding the previous experience as console surgeon, with 90.9% of the residents having performed at least a portion of a median of 15 procedures (IQR 2.5–35.5). Of the residents, 63.6% had previous experience with the da Vinci VR simulator, while the 50.5% had previous experience with training on the pigs.

Residents judged their baseline confidence using the Likert scale with port placement and docking, EndoWrist manipulation, Camera and Clutching, Fourth Arm Integration, and Needle Control and Driving with median scores of 3 (IQR 3–4), 3.5 (IQR 3–4), 4 (IQR 3–4), 3 (IQR 2–4), and 3 (IQR 2–3), respectively.

Post-training evaluation

Residents

On self-reassessment at the completion of robotic human cadaver training, the residents judged their confidence with port placement and docking, EndoWrist manipulation, Camera and Clutching, Fourth Arm Integration, and with Needle Control and Driving with median scores of 4 (IQR 4–5), 4 (IQR 4–5), 4 (IQR 4–5), 4 (IQR 4–4), and 4 (IQR 3–4), with perceived significant improvement in all the skills (P = .009, .002, .045, .002, and < .001, respectively, Fig. 1).

FIG. 1.

Box and Whisker plots depicting residents' answers about their self-assessment of confidence with (A) ports placement and docking, (B) EndoWrist^® manipulation, (C) Camera and Clutching, (D) Fourth Arm Integration, and (E) Needle Control and Driving. For each plot, answers to the baseline survey were reported on the left and answers to the post-training survey on the right.

The residents rated their overall improvement in robotic skills after training with a score of 5 (IQR 4–5). Almost all of them (19/22, 86.4%) rated the cadaver training globally with a score of 5 (median 5, IQR 5–5) (Fig. 2).

FIG. 2.

Radar plots depicting residents' answers about the perceived (A) overall improvement in robotic skills after the training, (B) the overall evaluation of the robotic cadaver training, and (C) the recommendation to another colleague.

When asked if they would recommend the human cadaver training to another colleague, the residents answered a median of 5 (IQR 5–5), with 19/22 residents (86.4%) answering 5 (“absolutely yes”).

Interestingly, the answers of the residents when asked about the superiority of human cadaver laboratory with respect to the VR simulator and to the pig laboratory were a median of 5 (IQR 5–5) and 4 (IQR 3–5), where 1 was not at all and 5 was absolutely superior.

Conversely, when asked to evaluate if cadaver training is noninferior to performing the procedure on a patient, the answer was uncertain with a median of 3 (IQR 2.5– 4) (Fig. 3).

FIG. 3.

Radar plots depicting residents' answers about (A) superiority of human cadaver laboratory with respect to the dVVR simulator, (B) with respect to pig laboratory, and about (C) noninferiority to the procedure on the human. dVVR, da Vinci Virtual Reality.

At univariate regression, an increasing number of procedures performed as console surgeon (both as continuous and categorical regressor) and more advanced residency program year were inversely associated with improvement in the “camera and clutching” skill (P = .048, beta −0.44, 95% CI −0.890 to −0.003 and P = .046, beta −0.429, 95% CI −0.850 to −0.007). No other significant effects were found when testing other possible predictors.

Supervisors

At the end of the training session, the five supervisors were asked to evaluate if the residents have improved their confidence with ports placement and docking, EndoWrist manipulation, Camera and Clutching, Fourth Arm Integration, and Needle Control and Driving: the median answers were 5 (IQR 4–5), 5 (IQR 5–5), 5 (IQR 5–5), 5 (IQR 4–4), and 5 (IQR 5–5), respectively (where 1 was not at all and 5 was absolutely yes), with a median overall score of 5 (IQR 5–5).

The supervisors believed the human cadaver training to be superior to the da Vinci simulator and the pig laboratory in improving the residents' robotic skills, with a median score of 5 (IQR 4–5) and 4 (IQR 4–5), respectively.

Their answers were slightly less enthusiastic when they were asked if the cadaver training is noninferior to the procedure on a patient, with a median of 4 (IQR 4–4).

The degree of recommendation of the human cadaver training was a five among all staff.

Discussion

Young surgeons continue to seek effective educational programs to learn the robotic technique, because of the significant need to rapidly acquire skills for their application in clinical practice.

Hands-on educational activities are generally thought of as being more effective than other continuing medical education activities in changing physician attitude, performance and, ultimately, improving patient care, and this is particularly true for robotic surgery.³

Indeed, thanks to the commitment of a coordinating director and a dedicated faculty, hands-on training focused on robotic surgery is periodically held at our institution. Beyond didactic lectures, video presentations, and live surgery sessions in the operative room, they have to include simulator- and animal-based laboratory experiences.

Exposure to a human cadaver laboratory is a rare opportunity and it is logistically challenging to organize the attendance of an entire residency in one course. Given this perceived opportunity, a dedicated robotic human cadaver training day was organized.

As demonstrated by the results, the course was positively perceived by both the trainers and the trainees and had an immediate impact on the overall confidence of the residents with their robotic skills regardless of the previous experience of the latter.

Having said this, the residents who were already familiar with robotics (i.e., those at a more advanced residency program year and/or those who had more consistent experience as console surgeon) reported minor improvement in their confidence with the camera and clutching skill.

The most likely explanation of this finding is that such a skill is one of the easiest to learn when starting with robotics. Indeed, no improvement was recorded in the residents with more consistent experience because they self-reported maximum confidence with the skill on the baseline assessment.

The necessity of robotic surgical training during residency is a matter of debate.¹⁹ With the recent boom in technology and an ever-increasing number of specialized procedures to teach, it is likely that elective additional training in more advanced techniques will be needed in the future, depending on interest and aptitude.²⁰

As robotic-assisted surgery continues to grow and become more popular, urology programs will need to develop methods for training residents, and continuing medical education programs will similarly need to incorporate robotic training in their curriculums for the practicing surgeon.^21,22

With the exponential growth of robotic urological surgery, guidelines for safe initiation of this technology will become a necessity. With a step in the right direction, the Society of Urologic Robotic Surgeons recently initiated a discussion about the need for implementing guidelines and proctoring recommendations.²³

We disclose that this study was not devoid of limitations. First, despite the 100% response rate of the surveys, the sample size analyzed was limited, but represented the whole institutional residents' pool. The experience with robotic training and robotic surgery varied through the analyzed cohort. Nevertheless, the characteristics of the participants (i.e., age, residency program year, access to robotic training and surgery, and so on) reflect the real-life composition of a teaching hospital.

Second, we acknowledge a bias potentially limiting the generalizability of our findings: it is reasonable to argue that many residents were pushed to give positive answers by the enthusiasm with the training day. To limit this potential bias, the administered survey was anonymous. Moreover, the residents were blinded to the post-training survey when answering to the baseline survey.

Third, the questionnaire used is not validated, but was purpose created instead.

Fourth, we did not take into account the impact of the human cadaver training beyond the study day. Instead, we focused our attention on the immediate effect of a single-session robotic cadaver training in the perceived improvement of introductory robotic skills.

Notwithstanding these limitations, the article is a rare report of robotic human cadaver training for residents, demonstrating the immediate effect on the residents' confidence with robotic surgery even after a single session.

In conclusion, in our experience, a single session of robotic human cadaver training among residents seemed to significantly improve confidence with their robotic surgical skills, regardless of previous experience. Robotic human cadaver training could be incorporated in the future as part of a standard educational model.

Footnotes

Disclosure Statement

Jihad H. Kaouk certifies that all conflicts of interest, including specific financial interests and relationships, and affiliations relevant to the subject matter or materials discussed in the article (e.g., Employment/affiliation, grants or funding, consultancies, honoraria, stock ownership or options, expert testimony, royalties, or patent filed, received or pending) are the following: Endocare, Inc, Intuitive.

The remaining authors, Riccardo Bertolo, Juan Garisto, Julien Dagenais, and Daniel Sagalovich have nothing to disclose.

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